From targets to solutions: Implementing a trauma quality improvement bundle in Cameroon.

BACKGROUND: Global surgery research efforts have been criticized for failure to transition from problem identification to intervention implementation. We developed a context-appropriate trauma quality improvement (TQI) bundle to ameliorate care gaps at a regional referral hospital in Cameroon. We determined associations between bundle implementation and improvement in trauma resuscitation practices. METHODS: We implemented a TQI bundle consisting of a hospital-specific trauma protocol, staff training, a trauma checklist, provision of essential emergency trauma supplies in the resuscitation area, and monthly quality improvement meetings. We compared trends in target process measures (e.g., frequency and timing of vital sign collection and primary survey interventions) in the six-month period pre- and post-bundle implementation using Wilcoxon rank-sum and Fisher's exact tests. RESULTS: We compared 246 pre-bundle patients with 203 post-bundle patients. Post-bundle patients experienced a greater proportion of all vital signs collected compared to the pre-intervention cohort (0 % pre-bundle vs. 69 % post-bundle, p < 0.001); specifically, the proportion of respiratory rate (0.8 % pre-bundle vs. 76 % post-bundle, p < 0.001) and temperature (7 % pre-bundle vs. 91 % post-bundle, p < 0.001) vital sign collection significantly increased. The post-bundle cohort had vital signs measured sooner (74 % vital signs measured within 15 min of arrival pre-bundle vs. 90 % post-bundle, p < 0.001) and more frequently per patient (7 % repeated vitals pre-bundle vs 52 % post-bundle, p < 0.001). Key primary survey interventions such as respiratory interventions (1 % pre-bundle vs. 8 % post-bundle, p < 0.001) and cervical collar placement (0 % pre-bundle vs. 7 % post-bundle, p < 0.001) also increased in the post-bundle cohort. CONCLUSIONS: The implementation of a context-appropriate TQI bundle was associated with significant improvements in previously identified trauma care deficits at a single regional hospital. Data-derived interventions targeting frontline capacity at the local level can bridge the gap between identifying care limitations and improvement in resource-limited settings.

Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting.

Objectives: We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation. Methods: We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test. Results: Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97). Conclusions: CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure. Level of evidence and study type: III, retrospective study.

Feasibility and acceptability of mobile phone-based triage tool to identify discharged trauma patients in need of further care in Cameroon.

Background: Lack of routine follow-up for trauma patients after hospital discharge likely contributes to high rates of injury-related complications in Cameroon. Mobile phone contact may facilitate timely follow-up and reduce disability for high-risk patients. A previous single-center study showed promising feasibility of mobile health (mHealth) triage, but generalizability remains unknown. We evaluated the feasibility and acceptability of implementing a postdischarge mHealth triage tool at four hospitals in Cameroon. Methods: Trauma patients from four Cameroonian hospitals were contacted at 2 weeks, 1, 3, and 6 months postdischarge. Program feasibility was assessed by calculating the proportion of successful contacts and overall cost. Odds of successful contact were compared using generalized estimating equations across patient socioeconomic status. Acceptability was assessed using a structured patient survey at 2 weeks and 6 months postdischarge. Results: Of 3896 trauma patients, 59% were successfully contacted at 2 weeks postdischarge. Of these, 87% (1370/1587), 86% (1139/1330), and 90% (967/1069) were successfully reached at the 1-month, 3-month, and 6-month timepoints, respectively. The median cost per patient contact was US$3.17 (IQR 2.29-4.29). Higher socioeconomic status was independently associated with successful contact; rural poor patients were the least likely to be reached (adjusted OR 0.11; 95% CI 0.04 to 0.35). Almost all surveyed patients reported phone-based triage to be an acceptable follow-up method. Conclusion: Telephone contact is a feasible and acceptable means to triage postdischarge trauma patients in Cameroon. While scaling an mHealth follow-up program has considerable potential to decrease injury morbidity in this setting, further research is needed to optimize inclusion of socioeconomically marginalized groups. Level of evidence: Level III, prospective observational study.

Mobile health follow-up screening to risk stratify patients in need of further care in a low resource setting: Results from a prospective multisite implementation study.

BACKGROUND: Routine in-person follow-up for injured patients after hospital discharge is unfeasible in low- and middle-income countries where trauma morbidity and mortality are the highest. Mobile technology screening may facilitate early detection of complications and timely treatment. In this prospective, multisite implementation study, we cross-validate the performance of a cellphone screening tool developed to risk stratify trauma patients in need of further care after discharge in Cameroon. METHODS: Between June 2019 and August 2022, research assistants contacted trauma patients by cellphone 2 weeks after discharge to administer a 14-question follow-up survey. All surveyed patients were asked to return for a physical examination. Physicians blinded to survey results categorized patients as low or moderate or high risk (HR) for poor outcomes without further care. Logistic regression tested associations between each survey question and physician examination. Predictive survey questions generated a preliminary model with high sensitivity for identifying patients in need of further care. RESULTS: Of 1,712 successfully contacted patient households, 96% (1643) participated in telephone triage compared with 33% (560) who returned for physician examination. Physicians designated 39% (220) as being HR. On multiple logistic regression, 8 of 13 candidate triage questions were independently associated with HR. Positive survey response on the resultant eight question screen yielded 89.2% sensitivity for HR with a 10.8% false negative rate. Weighted for variable importance based on triage risk scores, 39% of triaged patients screened as low risk, 39% as moderate risk, and 22% as high risk for HR. Likelihood of HR was significantly greater for patients screening as high (odds ratio, 5.9) or moderate risk (odds ratio, 1.9; both p < 0.01). CONCLUSION: Cellphone triage provides sensitive risk stratification of patients in need of further care after hospital discharge in Cameroon. Given low in-person return rates, limited resources should highly prioritize efforts to repatriate patients screening as high risk for poor outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper.

BACKGROUND: Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS: A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS: CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS: Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

How trauma patients die in low resource settings: Identifying early targets for trauma quality improvement.

BACKGROUND: Injury deaths in sub-Saharan Africa are among the world's highest, but hospital data rarely have sufficient granularity to direct quality improvement. We analyzed clinical care patterns among trauma patients who died in a prospective, multicenter sub-Saharan cohort to pinpoint trauma quality improvement intervention targets. METHODS: In-hospital trauma deaths in four Cameroonian hospitals between 2017 and 2019 were included. Trauma registry data on patient demographics, injury characteristics, and clinical care were analyzed to identify opportunities for systems improvements. RESULTS: Among 9,423 trauma patients, there were 236 deaths. Overall, 83% of patients who died in the emergency department were living on arrival (LOA). Among 183 LOA patients, 30% presented with normal vital signs, but 11% had no vital signs taken, often because of lack of equipment (43%). Of LOA patients presenting with a Glasgow Coma Scale score of <9 (56%), few received neurosurgery consults (15%), C-collar placement (9%), or intubation (1%). The most common reason for lack of c-collar placement was failure to recognize that it was indicated (66%). Tracheal deviation, unequal breath sounds, or paradoxical chest movement were present in 63% of LOA patients, but only two patients had chest tubes placed. Hypotension or active bleeding was present in 80% of LOA patients; while crystalloid bolus was given to 96% of these patients, few received transfusion (8%), tourniquet placement for extremity injury (6%), or an operation (4%). CONCLUSION: Primary survey interventions are underperformed in trauma nonsurvivors in Cameroon. Protocolizing early treatment for head injury, hemorrhagic shock, and chest wall trauma could reduce trauma mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study.

OBJECTIVES: In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge. DESIGN: Prospective cohort study. SETTING: Four hospitals in the Littoral and Southwest regions of Cameroon. PARTICIPANTS: A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability. RESULTS: Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality. CONCLUSION: Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon.

Anorectal emergencies: WSES-AAST guidelines.

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Trauma quality indicators: internationally approved core factors for trauma management quality evaluation.

INTRODUCTION: Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them. MATERIAL AND METHODS: A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference RESULTS: An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects. CONCLUSION: Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.

Right population, right resources, right algorithm: Using machine learning efficiently and effectively in surgical systems where data are a limited resource.

There is a growing interest in using machine learning algorithms to support surgical care, diagnostics, and public health surveillance in low- and middle-income countries. From our own experience and the literature, we share several lessons for developing such models in settings where the data necessary for algorithm training and implementation is a limited resource. First, the training cohort should be as similar as possible to the population of interest, and recalibration can be used to improve risk estimates when a model is transported to a new context. Second, algorithms should incorporate existing data sources or data that is easily obtainable by frontline health workers or assistants in order to optimize available resources and facilitate integration into clinical practice. Third, the Super Learner ensemble machine learning algorithm can be used to define the optimal model for a given prediction problem while minimizing bias in the algorithm selection process. By considering the right population, right resources, and right algorithm, researchers can train prediction models that are both context-appropriate and resource-conscious. There remain gaps in data availability, affordable computing capacity, and implementation studies that hinder clinical algorithm development and use in low-resource settings, although these barriers are decreasing over time. We advocate for researchers to create open-source code, apps, and training materials to allow new machine learning models to be adapted to different populations and contexts in order to support surgical providers and health care systems in low- and middle-income countries worldwide.

Prevalence, care-seeking practices and impact of self-reported vision impairment in Southwest Cameroon: a community-based study.

OBJECTIVES: To establish the prevalence of self-reported vision impairment (VI) in Southwest Cameroon and describe associated care-seeking practices, functional limitations and economic hardships. DESIGN: A three-stage clustered sampling household community-based survey. SETTING: The Southwest region of Cameroon. PARTICIPANTS: 8046 individuals of all ages residing in the Southwest region of Cameroon. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of self-reported VI, onset of vision loss, care-seeking practices, diagnosis and treatment, functional limitations, economic hardships on household, beliefs about surgical treatability of blindness and barriers to surgical care. RESULTS: The estimated prevalence of self-reported VI in Southwest Cameroon was 0.87% (95% CI 0.62 to 1.21). Among participants aged ≥40 years, the prevalence increased to 2.61% (95% CI 1.74 to 3.90). Less than a quarter of affected participants reported difficulty working (20.5%) or trouble going to school (12.0%) as a result of their VI. Yet, over half (52%, n=43) of affected households experienced significant economic hardships due to the VI. Residing in an urban setting (aOR 1.16, 95% CI 1.04 to 1.30) and belonging to a higher socioeconomic status (aOR 1.13, 95% CI 1.02 to 1.26) were factors associated with the belief that certain types of blindness were surgically reversible. Formal care was not sought by 16.3% (n=8) of affected participants. Cataracts was the leading diagnosis among participants who did seek formal care (43.2%, n=16), although 93.8% of these cases were not surgically treated, primarily due to a lack of perceived need. CONCLUSION: The prevalence of individuals who report vision impairment in Southwest Cameroon is considerably lower than prior published estimates based on visual physical examinations. Routine community-level screening and cost financing schemes could improve detection of pre-clinical eye disease and the utilisation of surgical care. It could also pre-empt disability and economic hardships associated with advanced VI in the region.

Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery.

Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons' compliance with best practices even more important.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

BACKGROUND: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Feasibility of a Cellular Telephone Follow-Up Program After Injury in Sub-Saharan Africa.

BACKGROUND: Injury disproportionately affects persons in low- and middle-income countries (LMIC). Most LMIC lack capacity for routine follow-up care, likely resulting in complications and disability. Cellular telephones may provide a new tool to improve health outcomes. The objective of this study was to establish the feasibility of a mobile health follow-up program after injury in Cameroon. METHODS: Between February and October 2017, all injured patients admitted to a regional hospital in Cameroon were asked for mobile phone numbers as part of an existing trauma registry. Patients were contacted 2 weeks after leaving the hospital discharge to participate in a short triage survey. Data on program feasibility and patient condition were collected. RESULTS: Of 1180 injured patients who presented for emergency care, 83% provided telephone numbers, 62% were reached, and 48% (565) of all injured patients ultimately participated in telephone follow-up. Successfully contacted patients were reached after an average of 1.76 call attempts (SD 1.91) and median call time was 4.43 min (IQR 3.67-5.36). Five patients (1%) had died from their injuries at the time of follow-up. Among surveyed patients, 27% required ongoing assistance to complete activities of daily living. Nearly, half (47%) of patients reported inability to take medicines or care for their injury as instructed at discharge. Adequate pain control was achieved in only 38% of discharged patients. CONCLUSION: Pilot data suggest considerable under treatment of injury in Cameroon. Mobile telephone follow-up demonstrates potential as a feasible tool for screening discharged patients who could benefit from further care.

Acquisition of Surgical Skills by Final-Year Medical Students in State-Owned Medical Schools of Cameroon: Are We Doing Any Good?

INTRODUCTION: World Health Organization recommends that basic surgical care be administered at the district level. In the absence of qualified surgeons, general practitioners are sometimes proposed to bridge the gap. Medical curricula in low- and middle-income countries must be designed accordingly. The aim of this study was to assess the achievements of training of undergraduate medical students in Cameroon towards meeting this objective. METHODS: A descriptive cross-sectional study was carried out in the four state-owned medical schools in Cameroon. All students who had completed all clinical rotations were assessed with a self-administered questionnaire for their exposure and self-perceived comfort in conducting some selected basic surgical skills and procedures. RESULTS: A total of 304 (87.6%) students returned filled questionnaires. Their self-perceived comfort in surgical skills ranged from 25% (manual node tying) to 86% (surgical scrubbing). Adequate exposure to selected surgical procedures was 87% for repair of perineal tear complicating vaginal delivery, above 80% for caesarean section and incision and drainage of abscess, 73% for cast immobilization of extremity fracture and just above 50% for hernia repair and appendectomy. It was as low as 3% for bowel resection and anastomosis. The choice to perform extra-curricular activity for skills improvement was significantly associated with adequate exposure (p < 0.05). CONCLUSION: Overall, the mastery of practical surgical skills and basic surgical interventions by final-year medical students in Cameroon is insufficient. There is need to reinforce the training and assessment by creating the conditions for an appropriate exposure of medical students during surgical rotations.

Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

A Community-Based Assessment of Knowledge and Practice of Breast Self-Examination and Prevalence of Breast Disease in Southwest Cameroon.

INTRODUCTION: Despite the rising trend in breast cancer incidence and mortality across Sub-Saharan Africa, there remains a critical knowledge gap about the burden and patterns of breast disease and breast cancer screening practices at the population level. This study aimed to identify socioeconomic factors associated with knowledge and practice of breast self-examination (BSE) as well as assess the prevalence of breast disease symptoms among a mixed urban-rural population of women in the Southwest region of Cameroon. METHODS: We conducted a household-level community-based study in Southwest Cameroon between January and March 2017, using a three-stage cluster sampling framework. We surveyed 1287 households and collected self-reported data on 4208 female subjects, 790 of whom were household representatives. Each household representative provided information on behalf of all female household members about any ongoing breast disease symptoms. Moreover, female household representatives were questioned about their own knowledge and practice of BSE. RESULTS: Women demonstrated low frequency of knowledge of BSE, as 25% (n=201) of household representatives reported any knowledge of BSE; and among these only 15% (n=30) practiced BSE on a monthly basis. Age (aOR: 1.04), usage of Liquid Petroleum Gas fuel, a marker of higher socioeconomic status (aOR: 1.86), and speaking English as a primary language in the household (aOR: 1.59) were significant predictors of knowledge of BSE. Eleven women reported ongoing breast disease symptoms resulting in an overall prevalence of 2.3 cases of breast disease symptoms per 1000 women. CONCLUSIONS: Socioeconomic disparities in access to health education may be a determinant of knowledge of BSE. Community-based strategies are needed to improve dissemination of breast cancer screening methods, particularly for women who face barriers to accessing care.

Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.

Exploring the role of obesity and overweight in predicting postoperative outcome of abdominal surgery in a sub-Saharan African setting: a prospective cohort study.

OBJECTIVE: Current literature on the role of excess weight in predicting surgical outcome is controversial. In sub-Saharan Africa, there is extreme paucity of data regarding this issue in spite of the increasing rates of obesity and overweight in the region. This prospective cohort study, carried out over a period of 4 months at Limbe Regional Hospital in the Southwest region of Cameroon, assessed 30-day postoperative outcome of abdominal surgery among consecutive adults with body mass index (BMI) ≥ 25 kg/m2. Adverse postoperative events were reported as per Clavien-Dindo classification. RESULTS: A total of 103 patients were enrolled. Of these, 68.9% were female. The mean age was 38.2 ± 13.7 years. Sixty-four (62.1%) of the patients were overweight and the mean BMI was 29.2 ±4.3 kg/m2. The physical status scores of the patients were either I or II. Appendectomy, myomectomy and hernia repair were the most performed procedures. The overall complication rate was 13/103 (12.6%), with 61.5% being Clavien-Dindo grades II or higher. From the lowest to the highest BMI category, there was a significant increase in the proportion of patients with complications; 25-29.9 kg/m2: 6.25%, 30-34.9 kg/m2: 18.75%, 35-39.9 kg/m2: 25.0%, and ≥ 40 kg/m2: 66.70%; p = 0.0086.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion.

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The "surgeon champion" can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.