Implementation of a perioperative registry in Ethiopia to enhance surgical quality improvement.

BACKGROUND: Despite a glaring need and proven efficacy, prospective surgical registries are lacking in low- and middle-income countries. The objective of this study was to design and implement a comprehensive prospective perioperative registry in a low-income country. METHODS: This study was conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Design of the registry occurred from June 2021 to May 2022 and pilot implementation from May 2022 to May 2023. All patients undergoing elective or emergent general surgery were included. Following one year, operability and fidelity of the registry were analyzed by assessing capture rate, incidence of missing data, and accuracy. RESULTS: A total of 67 variables were included in the registry including demographics, preoperative, operative, post-operative, and 30-day data. Of 440 eligible patients, 226 (51.4%) were successfully captured. Overall incidence of missing data and accuracy was 5.4% and 90.2% respectively. Post pilot modifications enhanced capture rate to 70.5% and further optimized data collection processes. CONCLUSION: The establishment of a low-cost electronic prospective perioperative registry in a low-income country represents a significant step forward in enhancing surgical care in under-resourced settings. The initial success of this registry highlights the feasibility of such endeavors when strong partnerships and local context are at the center of implementation. Continuous efforts to refine this registry are ongoing, which will ultimately lead to enhanced surgical quality, research output, and expansion to other sites.

Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery.

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

American College of Surgeons Member Involvement in Global Surgery: Results from the 2015 Operation Giving Back Survey.

BACKGROUND: Five billion people worldwide lack access to safe surgery. American College of Surgeons (ACS) members have a strong history of humanitarian and volunteer work. Since its founding in 2004, Operation Giving Back (OGB) has served as a volunteer resource portal. This study sought to understand current activities, needs, and barriers to ACS member volunteerism, and to re-assess the role of OGB. METHODS: A 25-question electronic survey was sent to ACS members in August 2015. Utilizing branching logic, those who were involved or interested in volunteerism completed the full survey. Data were assessed using univariable analysis methods. RESULTS: Three percent (n = 1764) of those e-mailed answered the survey. Respondents were mostly men (82%), ≥50 years of age (61%), and general surgeons (70%). Fifty-three percent (n = 937) reported current or past volunteer activities, and 76.5% (n = 1349) were interested in activities within three years. Approximately 84% were interested in international volunteerism and 55% in domestic volunteerism. Few (5.7%) had both training and experience in emergency and disaster response, and only 17% had institutional salary support. Eighty-two percent wished to work with OGB, and 418 indicated organizations with whom they are involved could benefit from OGB collaboration. CONCLUSIONS: Interest in surgical volunteerism among ACS member survey respondents is high. OGB has the opportunity to meet member needs by developing programmatic activities, identifying volunteer prospects, facilitating multi-institutional consortia, and leading pre-deployment training. By maximizing volunteer efforts, OGB has the potential to foster sustainable and scalable ethical practices to improve basic access to surgical care globally.

PROMOTING GENDER EQUITY AT THE COLLEGE OF HEALTH SCIENCES, ADDIS ABABA UNIVERSITY, ETHIOPIA.

BACKGROUND: Ethiopia faces a dire shortage of human resources to meet the health care needs of its population of more than 90 million people. The government has implemented programs to expand the health care workforce, of which women are a growing and crucial component. Universities are working to identify and address gender inequity to help recruit and retain women. OBJECTIVE: This paper describes and analyzes a multi-institution grant-funded program to promote gender equity at Addis Ababa University-College of Health Sciences (AAU-CHS) in Ethiopia. METHODS: The primary intervention was to provide intensive short-term fellowships to mid-level female faculty to facilitate their promotion into leadership positions. Secondary interventions included a series of gender equity meetings with students, residents and staff to elicit bottom-up concerns and recommendations for future action, as well as conducting a gender climate survey of female students and staff External consultants assisted with program implementation, monitoring and evaluation of the program. RESULTS: Initial outcomes demonstrate promising career advancement of women who participated in the fellowships. A comprehensive gender equity action plan was developed based upon results from the survey and meeting recommendations. This plan is being implemented by AAU-CHS faculty and administration. CONCLUSION: This program has been an initial success and may serve as a template for others who are working to promote gender equity.

A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms.

OBJECTIVE: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. METHODS: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of >4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. RESULTS: Of the 1447 patients with rAAA, 65.5% underwent OS and 34.5% EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P < .0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P = .001). Amongst patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest ≤ 30 days (OS, 29.0%; EVAR, 19.1%; P = .006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P = .04). Amongst patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest ≤ 30 days (OS, 14.9%; EVAR, 11.6%; P = .20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P = .047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.10-2.43). CONCLUSIONS: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

Bilateral administration of autologous CD133+ cells in ambulatory patients with refractory critical limb ischemia: lessons learned from a pilot randomized, double-blind, placebo-controlled trial.

BACKGROUND AIMS: CD133+ cells confer angiogenic potential and may be beneficial for the treatment of critical limb ischemia (CLI). However, patient selection, blinding methods and end points for clinical trials are challenging. We hypothesized that bilateral intramuscular administration of cytokine-mobilized CD133+ cells in ambulatory patients with refractory CLI would be feasible and safe. METHODS: In this double-blind, randomized sham-controlled trial, subjects received subcutaneous injections of granulocyte colony-stimulating factor (10 µg/kg per day) for 5 days, followed by leukapheresis, and intramuscular administration of 50-400 million sorted CD133+ cells delivered into both legs. Control subjects received normal saline injections, sham leukapheresis and intramuscular injection of placebo buffered solution. Subjects were followed for 1 year. An aliquot of CD133+ cells was collected from each subject to test for genes associated with cell senescence. RESULTS: Seventy subjects were screened, of whom 10 were eligible. Subject enrollment was suspended because of a high rate of mobilization failure in subjects randomly assigned to treatment. Of 10 subjects enrolled (7 randomly assigned to treatment, 3 randomly assigned to control), there were no differences in serious adverse events at 12 months, and blinding was preserved. There were non-significant trends toward improved amputation-free survival, 6-minute walk distance, walking impairment questionnaire and quality of life in subjects randomly assigned to treatment. Successful CD133+ mobilizers expressed fewer senescence-associated genes compared with poor mobilizers. CONCLUSIONS: Bilateral administration of autologous CD133+ cells in ambulatory CLI subjects was safe, and blinding was preserved. However, poor mobilization efficiency combined with high CD133+ senescence suggests futility in this approach.

Learning from developing countries in strengthening health systems: an evaluation of personal and professional impact among global health volunteers at Addis Ababa University's Tikur Anbessa Specialized Hospital (Ethiopia).

BACKGROUND: The positive impact of global health activities by volunteers from the United States in low-and middle-income countries has been recognized. Most existing global health partnerships evaluate what knowledge, ideas, and activities the US institution transferred to the low- or middle-income country. However, what this fails to capture are what kinds of change happen to US-based partners due to engagement in global health partnerships, both at the individual and institutional levels. "Reverse innovation" is the term that is used in global health literature to describe this type of impact. The objectives of this study were to identify what kinds of impact global partnerships have on health volunteers from developed countries, advance this emerging body of knowledge, and improve understanding of methods and indicators for assessing reverse innovation. METHODS: The study population consisted of 80 US, Canada, and South Africa-based health care professionals who volunteered at Tikur Anbessa Specialized Hospital in Ethiopia. Surveys were web-based and included multiple choice and open-ended questions to assess global health competencies. The data were analyzed using IBRM SPSS® version 21 for quantitative analysis; the open-ended responses were coded using constant comparative analysis to identify themes. RESULTS: Of the 80 volunteers, 63 responded (79 percent response rate). Fifty-two percent of the respondents were male, and over 60 percent were 40 years of age and older. Eighty-three percent reported they accomplished their trip objectives, 95 percent would participate in future activities and 96 percent would recommend participation to other colleagues. Eighty-nine percent reported personal impact and 73 percent reported change on their professional development. Previous global health experience, multiple prior trips, and the desire for career advancement were associated with positive impact on professional development. CONCLUSION: Professionally and personally meaningful learning happens often during global health outreach. Understanding this impact has important policy, economic, and programmatic implications. With the aid of improved monitoring and evaluation frameworks, the simple act of attempting to measure "reverse innovation" may represent a shift in how global health partnerships are perceived, drawing attention to the two-way learning and benefits that occur and improving effectiveness in global health partnership spending.

Development and implementation of an emergency medicine graduate training program at Addis Ababa University School of Medicine: challenges and successes.

BACKGROUND: Ethiopians experience high rates of acute illness and injury that have been sub-optimally addressed by the existing health care system. High rates of patient morbidity and mortality prompted the Federal Ministry of Health (FMOH) and the Addis Ababa University School of Medicine (AAU-SM) to prioritize the establishment of emergency medicine (EM) as a medical specialty in Ethiopia to meet this acute health system need. OBJECTIVES: To review the EM residency training program developed and implemented at AAU-SM in partnership with the University of Wisconsin (UW), the University of Toronto (UT) and University of Cape Town (UCT) and to evaluate the progress and challenges to date. METHODS: An EM Task Force (EMTF) at AAU-SM developed a context-specific three-year graduate EM curriculum with UW input. This curriculum has been co-implemented by faculty teachers from AAU-SM, UT and UW. The curriculum together with all documents (written, audio, video) are reviewed and used as a resource for this article. RESULTS: Seventeen residents are currently in full-time training. Five residents research projects are finalized and 100% of residents passed their year-end exams. CONCLUSION: A novel graduate EM training program has been successfully developed and implemented at AAU-SM. Interim results suggest that this curriculum and tri-institutional collaboration has been successful in addressing the emergency health needs of Ethiopians and bolstering the expertise of Ethiopian physicians. This program, at the forefront of EM education in Africa, may serve as an effective model for future EM training development throughout Africa.

Development of pediatric emergency medicine at Addis Ababa University/Tikuranbessa Specialized Hospital, Ethiopia.

BACKGROUND: In the world emergencies occur everywhere, and each day they consume ressources regardless of whether there are systems capable of achieving good outcomes. Low-income countries suffer the most highest rates of every category of injury--from traffic and the highest rates of acute complications of communicable diseases including tuberculosis, malaria and HIV. OBJECTIVE: To describe the development of pediatrics emergency medicine at Tikur Anbesa Specialized Hospital METHODS: A twinning partnership model was used in developing a pediatric emergency medicine training program helps in development of pediatrics emergency system. RESULTS: Strengthening the capacity of Addis Ababa University (AAU), Tikur Anbessa Hospital (TASH) to provide pediatric emergency medical services through improved organization of the pediatrics emergency department and strengthening of continuing education opportunities for faculty and staff capacity building by this improving quality of care in pediatrics patients in the country. CONCLUSION: The Addis Ababa University, University of Wiscosin and People to People partners intend to continue working together to strengthening and developing effetive systems to deliver quality pediatrics emergency medicine care troughout all regions of Ethiopia.

Enhancing emergency medicine initiatives with a quality improvement program: lessons learned in the emergency department of Tikur Anbessa Hospital, Addis Ababa Ethiopia.

INTRODUCTION: A Twinning Partnership between the University of Wisconsin-Madison (UW) and Addis Ababa University (AAU) in Addis Ababa, Ethiopia was formed to strengthen the development of emergency medical services at AAU's Tikur Anbessa Specialized Hospital (TASHI) through medical education and exchanges. The Twinning philosophy which emphasizes collaboration and joint learning was an ideal program in which QI program was incorporated to maximize success, promote sustainability, and reinforce basic principles for effective healthcare service delivery. This article describes the QI methodology, capacity building strategy, implementation approach, and lessons learned. METHODOLOGY: QI initiative at TASH ED started during EM fellowship in 2010 when Priority problems in the department were identified, and root cause analysis and possible strategies for improvement were devised. Then Baseline and sensitization was undertaken which was followed by Quality Improvement Projects cycles. The Federal Ministry of health key performance indicators (KPI) were used as standard and measurement tool when it was relevant. The findings were analyzed and trends presented to the ED staff and other stakeholders. RESULTS: In the past four years Since QI initiatives started in TASH EM department different achievements have been registered. The main developments were capacity building with QI training of EM fellows, EM residents and EM and critical care nurses. QI Training was also conducted to Tikur Anbessa Hospital and college of health sciences leadership. In addition, various QI projects have been designed and started, while some are finalized and the rest are on implementation. DISCUSSION: The QI experience in the department suggests that a QI program can effectively support, complement, and enhance health system strengthening partnerships, and that establishment of a QI program at the department level is feasible and beneficial, enhancing the adoption and sustainability of health care improvements such as marked improvements in triage, improved infection control and other critical improvements. Therefore, program leaders have determined that scale-up to a hospital-wide QI program is needed to fully realize the potential for increased quality, efficiency and system strengthening.

Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department.

INTRODUCTION: Globally Emergency Medicine (EM) is young discipline and even in developed countries it is about five decades old. In Ethiopia formal pre-hospital care or hospital based Emergency department (ED) development is a recent phenomenon and this article describes development of Emergency Medicine care in Ethiopia before, around and after Ethiopia millennium. METHODOLOGY: Documents related to emergency medicine development and implementation from different government and nongovernmental data sources are used as a resource for this article. RESULTS: Emergency Medicine task force (EMTF) has been established in Addis Ababa University (AAU) school of Medicine (SOM) in June 2006 and the taskforce has closely worked with Federal Ministry of Health (FMOH) and Addis Ababa city council Health Bureau (AACCHB). In addition to the main actors many partners have contributed significantly to this initiative. Some of the developments were establishment of emergency departments in Tikur Anbessa Specialized Hospital (TASH) and the restructuring of EM service by FMOH. Emergency care has been considered as a crucial service in hospitals' service along with outpatient and inpatient services. Furthermore, Pre-hospital care initiatives have been commenced in Addis Ababa and expanded to the regions with a arrangement of one or two ambulances to small districts having 100,000 population. There have also been key achievement in human resource development, notably the establishment of EM residency and MSC in EM and critical care nursing. Prehospital care givers training programs in order to produce emergency medicine technicians (EMT) have been started in various regional health professionals training centers. Furthermore, EM module has been included in the current undergraduate medical education. The Ethiopian society of emergency professionals (ESEP) has been established with members from different categories of emergency medicine professionals. In all these developments the emergency medicine training center in the emergency department of AAU has played key role in the training of human resources in different categories. DISCUSSION AND CONCLUSION: The recent successes in EM development is due to concerted efforts of the FMOH, AAU SOM and AACCHB along with committed partners. Hence, it is concluded that consistent local efforts and relevant stakeholders support in EM has resulted in successful development of the field in the country.

Human- common hippo (Hippopotamus amphibius)-conflict in the Dhidhessa Wildlife Sanctuary and its surrounding, Southwestern Ethiopia.

The common hippopotamus (Hippopotamus amphibius) is one of the most endangered mega herbivore in Africa. Although the human-hippo conflict (HHC) is currently escalating due to habitat loss, little is known about the scope of the conflict and potential mitigation measures. From 2021 to 2022, the extent of HHC, the perception of local inhabitants towards the animal, and its impacts on the conservation of the hippo were assessed within and in the surrounding areas of Dhidhessa Wildlife Sanctuary, southwestern Ethiopia. A total of 227 households were used as a data sources, participating in the questionnaire survey, focus group discussion and key informant interviews. Direct field observations were also used as key data source. Crop raiding and damage (63%, n = 143), was the most severely reported source of conflict, followed by direct human attack (22.9%, n = 52). Livestock predation and increased hippo mortality were also common types of HHC in the area. According to the study, the majority of respondents (74.4%, n = 169) agreed that the trend of conflict was increasing, while 16.7% (n = 38) argued that there was no change. Food scarcities in the buffer zone, as well as agricultural expansion in the area, have been identified as major drivers of HHC. The majority of respondents had a negative attitude toward hippo conservation; however, there were differences based on gender, age, and educational level. The major traditional hippo conflict mitigation strategies in the area include guarding, fencing, and trenching. Field observation revealed that a large extent of the former grazing and ranging areas of hippo in the area are heavily encroached and taken over by large private and public agricultural investments. Vacating and recovering at least the former buffer areas dedicated to the wildlife in the area and modern, non-lethal mitigation strategies are recommended for better conservation and safeguarding of the currently good-sized hippo population of the sanctuary.

Barriers and Facilitators to Collecting Surgical Outcome Data in Low- and Middle-Income Countries: An International Survey.

Background: Perioperative data are essential to improve the safety of surgical care. However, surgical outcome research (SOR) from low- and middle-income countries (LMICs) is disproportionately sparse. We aimed to assess practices, barriers, facilitators, and perceptions influencing the collection and use of surgical outcome data (SOD) in LMICs. Methods: An internet-based survey was developed and disseminated to stakeholders involved in the care of surgical patients in LMICs. The Performance of Routine Information Systems Management framework was used to explore the frequency and relative importance of organizational, technical, and behavioral barriers. Associations were determined using χ 2 and ANOVA analyses. Results: Final analysis included 229 surgeons, anesthesia providers, nurses, and administrators from 36 separate LMICs. A total of 58.1% of individuals reported that their institution had experience with collection of SOD and 73% of these reported a positive impact on patient care. Mentorship and research training was available in <50% of respondent's institutions; however, those who had these were more likely to publish SOD (P = 0.02). Sixteen barriers met the threshold for significance of which the top 3 were the burden of clinical responsibility, research costs, and accuracy of medical documentation. The most frequently proposed solutions were the availability of an electronic data collection platform (95.3%), dedicated research personnel (93.2%), and access to research training (93.2%). Conclusions: There are several barriers and facilitators to collection of SOD that are common across LMICs. Most of these can be addressed through targeted interventions and are highlighted in this study. We provide a path towards advancing SOR in LMICs.

Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols.

OBJECTIVE: Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. METHODS: Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. RESULTS: From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). CONCLUSIONS: Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.

Clinical implications of non-contrast-enhanced computed tomography for follow-up after endovascular abdominal aortic aneurysm repair.

BACKGROUND: There is growing concern over the long-term radiation exposure from serial computed tomographic (CT) scan follow-up after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). Screening for endoleaks with non-contrast-enhanced volumetric CT has been shown to significantly reduce radiation doses. We evaluated the use of NCT as the primary method of follow-up after EVAR of AAAs. METHODS: Our institutional post-EVAR CT protocol consisted of contrast-enhanced CT angiography (CTA) 1 month after repair, followed by NCT at 3 or 6 and 12 months, and annually thereafter. At each follow-up scan, immediate 3-dimensional volume analysis was performed. If the volume change was <2%, NCT follow-up was continued. If the volume increased by ≥2% on nonenhanced images, contrast-enhanced CT was performed immediately to identify potential endoleaks. All images were reviewed by an experienced cardiovascular radiologist. End points included identification of endoleak, reintervention, and rupture. RESULTS: Over a 7-year period, 126 patients were followed. Serial CTA was performed in 59 patients, while 67 patients were followed with the NCT protocol. The mean follow-up was 2.07 years. There were no differences in age, sex, or initial aneurysm volume or size. There were 35 total endoleaks identified. Twenty of these were early endoleaks (<30 days post-EVAR). The remaining 15 leaks were late in nature (10 in the contrast group and 5 in the noncontrast group; P=0.17). NCT aneurysm sac volume changes prompted contrasted studies in all 5 late leaks. The mean volume change was 11.2 cm3, an average change of 5.88%. These findings were not significantly different than the late leaks found by routine contrast studies (8.9 cm3; 4.98% [P=0.58]). There were no delayed ruptures or emergent reinterventions in the NCT group. CONCLUSIONS: Serial NCT appears to be safe and effective as the sole means of follow-up after EVAR for AAAs. AAA volume increases of ≥2% should prompt further contrast-enhanced CT imaging. Changes of <2% can be safely followed with serial NCT. This protocol requires dedicated cardiovascular radiologist involvement, and patients should be retained in the radiology suite until real-time image evaluation can be completed.

Postgraduate Surgical Education in East, Central, and Southern Africa: A Needs Assessment Survey.

BACKGROUND: The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle-income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted. STUDY DESIGN: The American College of Surgeons Operation Giving Back, in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within 5 domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback. RESULTS: One-hundred sixty-six responses were received after 3 calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development. CONCLUSIONS: This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region.

Coaching for impact: successful implementation of a multi-national, multi-institutional synchronous research course in Ethiopia.

Purpose: Under the American College of Surgeons' Operation Giving Back, several US institutions collaborated with a teaching and regional referral hospital in Ethiopia to develop a surgical research curriculum. Methods: A virtual, interactive, introductory research course which utilized a web-based classroom platform and live educational sessions via an online teleconferencing application was implemented. Surgical and public health faculty from the US and Ethiopia taught webinars and led breakout coaching sessions to facilitate participants' project development. Both a pre-course needs assessment survey and a post-course participation survey were used to examine the impact of the course. Results: Twenty participants were invited to participate in the course. Despite the majority of participants having connection issues (88%), 11 participants completed the course with an 83% average attendance rate. Ten participants successfully developed structured research proposals based on their local clinical needs. Conclusion: This novel multi-institutional and multi-national research course design was successfully implemented and could serve as a template for greater development of research capacity building in the low- and middle-income country (LMIC) setting.

The effect of warfarin therapy on endoleak development after endovascular aneurysm repair (EVAR) of the abdominal aorta.

OBJECTIVES: The presence of an endoleak after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) may predispose to sac expansion and potential sac rupture. The incidence of endoleak after AAA repair can be as high as 20% to 30%. We investigated whether warfarin anticoagulation was an independent risk factor for endoleak after EVAR for AAA. METHODS: All AAA patients who underwent elective EVAR were prospectively followed-up. Data for demographics, clinical comorbidities, outcomes, EVAR devices, and anticoagulation methods were recorded. All patients underwent routine follow-up at 1, 6, and 12 months and annually thereafter. Computed tomography angiography (CTA) with 3-dimensional (3D) volumetric analysis was also completed. RESULTS: During a 7-year period, 127 consecutive patients with infrarenal AAAs who underwent EVAR were monitored for a mean of 2.14 years. The average age at the time of EVAR was 73.8 years. Warfarin therapy alone was administered to 24 patients, and anticoagulation with antiplatelet therapy alone was administered to 103. During the study period, 38 (29.9%) endoleaks were documented. The overall endoleak rate was 13 of 24 in the warfarin group and 25 of 103 in the antiplatelet group (P = .004). CTA 3D volumetric aneurysm sac analysis showed an increase of 16.09% in the warfarin study group and a reduction of 9.71% in the antiplatelet group (P = .04). CONCLUSIONS: Anticoagulation with warfarin appears to be linked to an increased risk for the development of endoleak after EVAR, specifically type II. Volumetric analysis showed warfarin therapy also contributed to persistent aneurysm sac expansion. These data suggest that patients who require warfarin anticoagulation for other indications should be advised that they might be at an increased risk for the development of endoleaks, subsequent secondary interventions, persistent sac expansion, and possible delayed sac rupture.

Endovascular abdominal aortic aneurysm repair: nonenhanced volumetric CT for follow-up.

PURPOSE: To evaluate the clinical usefulness of volumetric analysis at nonenhanced computed tomography (CT) as the sole method with which to follow up endovascular abdominal aortic aneurysm repair (EVAR) and to identify endoleaks causing more than 2% volumetric increase from the previous volume determination. MATERIALS AND METHODS: The study had institutional review board approval. Images were reviewed retrospectively in a HIPAA-compliant manner for 230 CT studies in 70 patients (11 women, 59 men; mean age, 74 years) who underwent EVAR. The scannning protocol consisted of three steps: (a) contrast material-enhanced CT angiography before endovascular stent placement, (b) contrast-enhanced CT angiography 0-3 months after repair to depict immediate complications, and (c) nonenhanced CT at 3, 6, and 12 months after repair. At each follow-up visit, immediate aortic volume analysis was performed. If the interval volumetric change was 2% or less, no further imaging was performed. If the volume increased by more than 2% on the nonenhanced CT image, contrast-enhanced CT angiography was performed immediately to identify the suspected endoleak. Confidence intervals (CIs) were obtained by using bootstrapping to account for repeated measurements in the same patients. RESULTS: Mean volume decrease was -3.2% (95% CI: -4.7%, -1.9%) in intervals without occurrence of a clinically relevant endoleak (n = 183). Types I and III high-pressure endoleaks (n = 10) showed a 10.0% (95% CI: 5.0%, 18.2%) interval volumetric increase. Type II low-pressure endoleaks (n = 37) showed a 5.4% (95% CI: 4.6%, 6.2%) interval volumetric increase. Endoleaks associated with minimal aortic volume increase of less than 2% did not require any intervention. This protocol reduced radiation exposure by approximately 57%-82% in an average-sized patient. CONCLUSION: Serial volumetric analysis of aortic aneurysm with nonenhanced CT serves as an adequate screening test for endoleak, causing volumetric increase of more than 2% from the volume seen at the previous examination.

Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008.

OBJECTIVE: Spinal fluid drainage reduces paraplegia risk in thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysm repair. There has not been a comprehensive study of the risks of spinal fluid drainage and how these risks can be reduced. Here we report complications of spinal fluid drainage in patients undergoing TAA/TAAA repair. METHODS: The study comprised 648 patients who had TAA or TAAA repair from 1987 to 2008. Spinal drains were used in 486 patients. Spinal fluid pressure was measured continuously, except when draining fluid, and was reduced to <6 mm Hg during thoracic aortic occlusion and reperfusion. After surgery, spinal fluid pressure was kept <10 mm Hg until patients were awake with normal leg lift. Drains were removed 48 hours after surgery. Spinal and head computed tomography (CT) scans were performed in patients with bloody spinal fluid or neurologic deficit. We studied the incidence of headache treated with epidural blood patch, infection, bloody spinal fluid, intracranial and spinal bleeding on CT, as well as the clinical consequences. RESULTS: Twenty-four patients (5%) had bloody spinal fluid. CT exams showed seven had no evidence of intracranial hemorrhage, 14 (2.9%) had intracranial blood without neurologic deficit, and three with intracranial bleeding and cerebral atrophy had neurologic deficits (1 died, 1 had permanent hemiparesis, and 1 with transient ataxia recovered fully). Two patients without bloody spinal fluid or neurologic deficit after surgery presented with neurologic deficits 5 days postoperatively and died from acute on chronic subdural hematoma. Neurologic deficits occurred after spinal fluid drainage in 5 of 482 patients (1%), and 3 died. The mortality from spinal fluid drainage complications was 0.6% (3 of 482). By univariate and multivariate analysis, larger volume of spinal fluid drainage (mean, 178 mL vs 124 mL, P < .0001) and higher central venous pressure before thoracic aortic occlusion (mean, 16 mm Hg vs 13 mm Hg, P < .0012) correlated with bloody spinal fluid. CONCLUSION: Strategies that reduce the volume of spinal fluid drainage but still control spinal fluid pressure are helpful in reducing serious complications. Patients with cerebral atrophy are at increased risk for complications of spinal fluid drainage.