Surgical Simulation Training for Medical Students: Strategies and Implications in Botswana.

BACKGROUND: The role of simulation in teaching technical skills to medical students is not yet well defined. Strategies for its use may be especially relevant where teachers, time, and resources are limited, especially in low-middle-income countries. METHODS: Sixty-seven third-year and 67 fifth-year medical students at the University of Botswana were taught surgical skills by a trained peer medical student, a medical officer with no specialty training or a staff surgeon. Pre- and post-intervention performance of two basic tasks (simple interrupted suture (SIS) and laparoscopic peg transfer (LPT)) and one complex task (laparoscopic intracorporeal suture (LIS)) were assessed. Subjective measures of self-perceived performance, preparedness for internship, and interest in surgery were also measured. RESULTS: The simulation program decreased the time to complete the two basic tasks and improved the objective score for the complex task. Performance of the basic skills improved regardless of the seniority of the instructor while performance of the advanced skill improved more when taught by a staff surgeon. All students had similar improvements in their self-reported confidence to perform the skills, preparedness to assist in an operation and preparedness for internship, regardless of the seniority of their instructor. Students taught by a staff surgeon felt better prepared to assist in laparoscopic procedures. CONCLUSION: Simulation-based teaching of defined surgical skills can be effectively conducted by peers and near-peers. The implications are widespread and may be most relevant where time and resources are limited, and where experienced teachers are scarce.

Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana.

BACKGROUND: Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana. METHODS: We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed. RESULTS: Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge. CONCLUSION: The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.

HIV Infection: Its Impact on Patients with Appendicitis in Botswana.

BACKGROUND: To compare the presentation, management, and outcome of HIV-positive patients with appendicitis to those of HIV-negative patients with appendicitis. SUMMARY BACKGROUND DATA: The literature is limited regarding the impact of HIV infection on patients with appendicitis. METHODS: A retrospective review of patients with appendicitis and known HIV status admitted to Princess Marina Hospital, Gaborone, Botswana, aged 13 years and greater was performed from January 2013 to December 2015. Data on patient demographics, presentation, laboratory findings, management, and outcomes were analyzed. RESULTS: A total of 295 patients with appendicitis and known HIV status were identified, of which 119 (40.3%) were HIV positive. The median [IQR] ages for HIV-positive and HIV-negative patients were 34 [29-42] and 26 [20-33] years, respectively. The male-to-female ratio for the same two groups was 0.8:1 and 1.4:1, respectively. Presenting symptoms, signs, and white blood cell count were similar in both groups. HIV-positive patients had significantly higher overall (4.2 vs. 0.0%, p = 0.010) and postoperative (4.4 vs. 0.0%, p = 0.024) mortality rates. There was no significant difference in the total complication rate between HIV-positive and HIV-negative patients (13.2 vs. 7.9%, p = 0.192). Compared to HIV-positive patients with a CD4 count ≥200, patients with a CD4 count <200 have a significantly higher postoperative mortality rate (17.6 vs. 1.4%, p = 0.023) and a trend toward a higher total postoperative complication rate (31.3 vs. 10.8%, p = 0.054). CONCLUSION: Within our setting, HIV infection, particularly with a CD4 <200, was correlated with significantly higher mortality in patients with acute appendicitis.

The impact of HIV infection on surgical gastrointestinal diseases at the Princess Marina Hospital, Gaborone, Botswana: a cross-sectional study.

Introduction: various gastrointestinal diseases affect surgical patients. Literature on the burden and outcomes of surgical gastrointestinal diseases in a high HIV infection prevalence is scares. This study aimed to investigate this topic at the Princess Marina Hospital. Methods: medical records of patients admitted with surgical gastrointestinal diseases to adult surgical wards were reviewed from August 2017 to July 2018. Demographics, date of admission and discharge, HIV status, CD4 count, and outcomes were analyzed. Results: six-hundred and ninety-eight (698) patients with known HIV infection status and surgical gastrointestinal diseases were admitted. HIV+ patients contributed 274 (39.3%). Among HIV+, females contributed 147 (53.6%). Symptomatic gallbladder stone disease was significantly higher in HIV- patients, p=0.008; while anal cancers, p=0.001, anal warts, p=0.001, and perianal infections and fistulae, p=0.010 were significantly higher in HIV+ patients. Overall, surgical site infections were recorded in 15 (2.1%) and mortalities in 43 (6.2%). The mortality rate was higher in HIV+ than in HIV- patients, p=0.048. The total number of surgical procedures and median hospital stays among HIV- and HIV+ patients were not statistically significant, p=0.868 and p=0.249 respectively. The total number of complications, p=0.338, mortality, p=0.149, and median hospital stay, p=0.181, among HIV+ patients based on CD4 count, < 200 vs. > 200, were not significantly different. Conclusion: symptomatic gallbladder stone diseases were significantly higher in HIV- patients; while anal cancer, anal warts, and perianal infections and perianal fistulae were significantly higher in HIV+ patients. HIV+ patients had a significantly higher mortality rate than HIV- patients, and this needs further investigation.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

The clinical characteristics and outcomes of appendicitis in a population with a high HIV-infection prevalence.

Introduction: In Botswana, the prevalence of HIV-infection is high (20.1%). Literature on characteristics of appendicitis in a high HIV-infection prevalence is limited. Method: A retrospective medical records review was conducted in patients admitted with a diagnosis of appendicitis and known HIV-infection status to adult surgical wards at Princess Marina Hospital from 2013 to 2019. Patients' demographics, clinical characteristics, laboratory data, management and outcomes were analysed. Results: A total of 601 appendicitis patients with known HIV-infection status were identified. Males contributed 51.9%. The overall median age was 29-year: 25-year for HIV-negative patients (HIV-NP) and 36-year for HIV-positive patients. HIV-NP had significantly higher rate of WBC count >10,000/µL, p=0.034. Appendectomy was performed in 92.8% of the cases. Non-operative treatment failure rate in one year was 35.4%. A total of 58 complications were recorded including 20 surgical site infections (SSIs) and one mortality in HIV-NP and 11 SSIs and six mortalities in HIV-positive patients (HIV-PP). HIV-PP had significantly higher mortality than HIV-NP, p=0.010. The overall hospital stay between operated and non-operated patients, p=0.996 and hospital stay between HIV-NP and HIV-PP were not different, p=0.223. Female patients had a significantly higher normal appendix and chronic appendicitis rates than males, p=0.032 and p=0.018 respectively. Complex appendicitis was associated with longer pre-hospital symptom duration, p=0.008 and longer hospital stay, p= 0.001, but it was not related to mortality, p=1.000. Among operated HIV-PP, patients with CD4 count <200 had a significantly higher mortality rate than those with ≥200, p=0.043. Conclusion: In Botswana, the prevalence of HIV-infection in patients with appendicitis was higher than the rate in the general population. HIV-infection and low CD4 count had an adverse effect on the mortality of patients with appendicitis. The higher HIV-infection rate in appendicitis patients and the impact of antiretroviral drug and viral-load on the outcomes in HIV-PP worth investigating.

Pathology for Thoracic Conditions in Low- and Middle-Income Countries.

Pulmonary disease in low- and middle-income countries is highly diverse and dependent on the population, background epidemiology, environmental exposures, and smoking status. Credible evaluation of lung diseases requires skilled clinicians, imaging infrastructure, microbiology, and pathologic diagnostics, including imaging-guided cytology and biopsy. When these tools are available, improvement in patient outcomes is feasible. Pathologic diagnostics of lung lesions, including histology, immunohistochemistry, and molecular testing, are critical to properly stratify patient risk and determine exact therapies for each patient. A critical focus on research and directed interventions in lung cancer treatment specifically is needed to downstage this disease and improve patient outcome.

Job Satisfaction and Its Determinants among Nurse Anesthetists in Clinical Practice: The Botswana Experience.

Job satisfaction (JS) correlates positively with patients' satisfaction and outcomes and employees' well-being. In Botswana, the level of job satisfaction and its determinants among nurse anesthetists were not investigated. A cross-sectional study was conducted from January 2020 to June 2020 encompassing all nurse anesthetists in clinical practice in Botswana. A self-administered questionnaire was used that incorporated demographic data, reasons to stay on or leave their job, and a validated 20-item short form of the Minnesota Satisfaction Questionnaire which was pretested on five of our nurse anesthetists. Percentage is used to describe the data. The independence of categorical variables was examined using chi-square or Fisher's exact test. p value <0.05 was considered statistically significant. In Botswana, a total of 76 nurse anesthetists were in clinical practice during the study period. Sixty-six (86.9%) responded to the survey. Gender distribution was even, 50.0%. The overall JS was 36.4%. Males had significantly higher JS than females, p = 0.001. Significantly higher job satisfaction was found in married nurse anesthetists (p = 0.039), expatriate nurse anesthetists (p = 0.001), nurse anesthetists in non-referral hospitals (p = 0.023), and nurse anesthetists with ≥10 years' experience (p = 0.019). Nurse anesthetists were satisfied with security, social service, authority, ability utilization, and responsibility in ≥60.0% of the cases. They were not satisfied in compensation, working condition, and advancement in a similar percentage. The main reason to stay on their job was to serve the public in 68.2%. In Botswana, employers should make an effort to address the working conditions, compensation, and advancement of nurse anesthetists in clinical practice.

The characteristics and outcomes of trauma admissions to an adult general surgery ward in a tertiary teaching hospital.

BACKGROUND: Traumatic injuries are proportionally higher in low- and middle-income countries (LMICs) than high-income counties. Data on trauma epidemiology and patients' outcomes are limited in LMICs. METHODS: A retrospective review of medical records was performed for trauma admissions to the Princess Marina Hospital general surgical (GS) wards from August 2017 to July 2018. Data on demographics, mechanisms of injury, body parts injured, Revised Trauma Score, surgical procedures, hospital stay, and outcomes were analysed. RESULTS: During the study period, 2610 patients were admitted to GS wards, 1307 were emergency admissions. Trauma contributed 22.1% (576) of the total and 44.1% of the emergency admissions. Among the trauma admissions, 79.3% (457) were male. The median[interquartile range(IQR)](range) age in years was 30[24-40](13-97). The main mechanisms of injury were interpersonal violence (IPV), 53.1% and road traffic crashes (RTCs), 23.1%. More females than males suffered animal bites (5.9% vs. 0.9%), and burns (8.4% vs. 4.2%), while more males than females were affected by IPV (57.8% vs. 35.3%) and self-harm (5.5% vs. 3.4%). Multiple body parts were injured in 6.6%, mainly by RTCs. Interpersonal violence (IPV) and RTCs resulted in significant numbers of head and neck injuries, 57.3% and 22.2% respectively. More females than males had multiple body-parts injury 34.5% vs. 18.5%. Revised Trauma Score (RTS) of ≤11 was recorded in IPV, 38.4% and RTCs, 33.6%. Surgical procedures were performed on 44.4% patients. The most common surgical procedures were laparotomy (27.8%), insertion of chest tube (27.8%), and craniotomy/burr hole(25.1%). Complications were recorded in 10.1% of the patients(58) including 39 deaths, 6.8% of the 576. CONCLUSION: Trauma contributed significantly to the total GS and emergency admissions. The most common mechanism of injury was IPV with head and neck the most frequently injured body part. Further studies on IPV and trauma admissions involving paediatric and orthopaedic patients are warranted.

Successful spinal anaesthesia for caesarean section in an African patient with Takayasu's arteritis.

Takayasu's arteritis (TA) is a rare chronic inflammatory disease affecting mainly the aorta and its main branches. We report a case of a 24-year-old primigravida, an African patient, with TA planned for caesarean section at 37 weeks of gestation. Clinically, she has involvement of aortic arch and its branches and abdominal aorta. She underwent caesarean section and delivered an alive baby boy under successful spinal anaesthesia with insignificant complications. Although it is rare in the African continent, anesthesiologists should be up-to-date with the knowledge of perioperative anesthetic management of TA in pregnant cases requiring operative delivery.

An International Surgical Rotation as a Systems-Based Elective: The Botswana-University of Pennsylvania Surgical Experience.

OBJECTIVE: There is a growing need to address the global burden of surgical disease along with increasing interest in international surgical practice, necessitating an understanding of the challenges and issues that arise on a systems level when practicing abroad. DESIGN: This elective is a month-long rotation in which senior surgical residents participate in patient care as part of a surgical team in the main tertiary and teaching hospital in Gaborone, the capital city of Botswana. Clinical experience is combined with formal readings and educational sessions, with the attending surgeon supervising the program to develop a systems-based curriculum that contextualizes the clinical experience. A formal debriefing and written reflections by the residents at the conclusion of the rotation are used to qualitatively assess resident development and insight into systems-based international surgical practice. SETTING: Princess Marina Hospital, Gaborone, Botswana. PARTICIPANTS: General surgery residents in their fourth clinical year of training. RESULTS: Our elective met important requirements outlined in the literature for foreign practice, including adequate supervision of the American trainees and care to not detract from local trainees' educational experience. Residents' debriefing and written reflections demonstrated an increased understanding of systems-based practice and awareness of issues important to successful international surgical practice and collaboration. CONCLUSIONS: Our global surgery elective with a focus on systems-based practice sensitizes residents to the challenges and issues they must be aware of when practicing internationally.

Surgery in global health delivery.

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.