Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.

INTRODUCTION: Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs). METHODS: We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15. RESULTS: The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions. CONCLUSION: Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.

A multimodal mentorship intervention to improve surgical quality in Tanzania's Lake Zone: a convergent, mixed methods assessment.

BACKGROUND: Safe, high-quality surgical care in many African countries is a critical need. Challenges include availability of surgical providers, improving quality of care, and building workforce capacity. Despite growing evidence that mentoring is effective in African healthcare settings, less is known about its role in surgery. We examined a multimodal approach to mentorship as part of a safe surgery intervention (Safe Surgery 2020) to improve surgical quality. Our goal was to distill lessons for policy makers, intervention designers, and practitioners on key elements of a successful surgical mentorship program. METHODS: We used a convergent, mixed-methods design to examine the experiences of mentees, mentors, and facility leaders with mentorship at 10 health facilities in Tanzania's Lake Zone. A multidisciplinary team of mentors worked with surgical providers over 17 months using in-person mentorship, telementoring, and WhatsApp. We conducted surveys, in-depth interviews, and focus groups to capture data in four categories: (1) satisfaction with mentorship; (2) perceived impact; (3) elements of a successful mentoring program; and (4) challenges to implementing mentorship. We analyzed quantitative data using frequency analysis and qualitative data using the constant comparison method. Recurrent and unifying concepts were identified through merging the qualitative and quantitative data. RESULTS: Overall, 96% of mentees experienced the intervention as positive, 88% were satisfied, and 100% supported continuing the intervention in the future. Mentees, mentors, and facility leaders perceived improvements in surgical practice, the surgical ecosystem, and in reducing postsurgical infections. Several themes related to the intervention's success emerged: (1) the intervention's design, including its multimodality, side-by-side mentorship, and standardization of practices; (2) the mentee-mentor relationship, including a friendly, safe, non-hierarchical, team relationship, as well as mentors' understanding of the local context; and (3) mentorship characteristics, including non-judgmental feedback, experience, and accessibility. Challenges included resistance to change, shortage of providers, mentorship dose, and logistics. CONCLUSIONS: Our study suggests a multimodal mentorship approach is promising in building the capacity of surgical providers. By distilling the experiences of the mentees, mentors, and facility leaders, our lessons provide a foundation for future efforts to establish effective surgical mentorship programs that build provider capacity and ultimately improve surgical quality.

Utility of ultrasound guided versus conventional fine needle aspiration cytology in diagnosing breast malignancies among patients with palpable breast lumps at Bugando Medical Centre, Mwanza Tanzania.

INTRODUCTION: breast lump is the commonest presentation for both benign and maligant breast conditions. Both ultrasound guided and conventional fine needle aspiration cytology (FNAC) have been used for diagnosing of breast malignancy among patients with palpable breast lumps. This study compared diagnostic utility of ultrasound guided versus conventional FNAC in diagnosing breast malignancies among patients with palpable breast lumps at Bugando Medical Centre. METHODS: this was a hospital based cross sectional study with a follow up component that combined both retrospective data (from January 2017 to June 2018) and prospective data (from July 2018 to June 2019). RESULTS: during the study, total of 354 patients (male; female = 1: 32) were enrolled in the study. A total of 134 (37.9%) patients had malignant lesions while 220 (62.1%) of patients had benign lesions confirmed on histology. The diagnostic utility (sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy) for conventional FNAC was 86.7%, 95.7%, 93.5%, 91.1% and 92.0% with an 8% error margin versus ultrasound guided FNAC all were 100% with a 0% error margin respectively. CONCLUSION: both ultrasound guided and conventional FNAC show almost perfect agreement with histology. However, ultrasound guided FNAC has a higher diagnostic utility relative to conventional FNAC in diagnosing breast malignancies.

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND: Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings. METHODS: We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers. RESULTS: Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. CONCLUSION: Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania.

INTRODUCTION: Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates. METHODS: We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018. RESULTS: During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05). CONCLUSION AND RECOMMENDATIONS: Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania's National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

Predictors of Mortality Among Pediatric Burn Patients in East Africa.

Little is known about the outcomes of pediatric burn patients in resource-limited and rural locations of the developing world. In March 2013, our pediatric burn unit existing in this setting established an electronic registry of all patients. The authors analyzed the registry to determine overall mortality rates and predictors of mortality, including that of underweight status and body part burned. The secure electronic database of all admissions was reviewed for age, gender, weight, burn percentage (TBSA%), body part burned, cause/place of injury, length of stay, underweight status, surgery performed, reason for discharge, and mortality. Univariable and multivariable logistic regression was used to determine the variables associated with mortality. Kaplan-Meier curves were also analyzed. A total of 211 cases (59.7% male) admitted from March 2013 to June 2014 were reviewed. The median age, %TBSA, and length of stay were 2.0 years (1.3-3.3), 8.0% (5.0-13.4), and 8.5 days (4-14). The overall mortality rate was 15/211 (7.1%). Most injuries were unintentional (93.8%) scalds (85.3%) occurring in the home (98.1%). Two factors were significantly associated with mortality in the final multivariable model: %TBSA (odds ratio = 1.31 for 1% increase in %TBSA; 95% confidence interval = 1.17-1.46) and younger age (odds ratio = 0.20; 0.07-0.63). This study characterizes mortality among patients at a pediatric burn unit serving a rural population in the developing world. The majority of pediatric burns were unintentional scalds occurring in the home. %TBSA and lower age were the strongest predictors of mortality. Burn location and underweight status were not independent predictors of mortality. Overall mortality was 7.1%. These data are applicable to improving outcomes for patients in this burn unit and similar settings of its kind.

Dynamic bowel obstruction: aetiology, clinical presentation, management and outcome at Bugando Medical Centre, Mwanza, Tanzania.

Dynamic bowel obstruction is a common and potentially dangerous surgical emergency with high morbidity and mortality worldwide. No prospective study has been done on this subject in our setting. This study was conducted to describe in our region, the aetiology, clinical presentation, management and outcome of dynamic bowel obstruction. Data were analyzed using SPSS software system. A total of 342 patients were studied. Males outnumbered females by a ratio of 2.1: 1. The median age of patients at presentation was 34 years (range 11 to 78 years). Obstructed hernias (32.7%) were the commonest cause of dynamic bowel obstruction. Abdominal pain (100%) and vomiting (86.5%) were the most frequent presenting symptoms. Thirty-one (9.1%) patients were HIV positive. Small bowel was the commonest site of obstruction accounting for 89.2% of cases. Herniorrhaphy was the most frequent surgical procedure performed in 112 (32.7%) patients. Surgical site infection (38.8%) was the most common post-operative complication and it was significantly associated with HIV positivity and low CD 4+ count (p < 0.001). The overall median of length of hospital stay was 26 days (range 1 to 72 days). Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p = 0.022). Mortality rate was 14.3%. Delayed presentation, HIV positivity, low CD 4 count (< 200 cells/µl), high ASA class and presence of complications were the main predictors of mortality (p < 0.001). Obstructed hernias remain the commonest cause of dynamic bowel obstruction in our setting and contribute significantly to high morbidity and mortality. The majority of patients present late when the disease becomes complicated. Early diagnosis and timely definitive treatment are essential in order to decrease the morbidity and mortality associated with this disease.

Surgical education at Weill Bugando Medical Centre: supplementing surgical training and investing in local health care providers.

Global surgery initiatives increasingly are focused on strengthening education and local health care systems to build surgical capacity. The goal of this education project was to support local health care providers in augmenting the surgical curriculum at a new medical school, thus promoting long-term local goals and involvement. Working with local surgeons, residents, and medical and assistant medical officer students, we identified the most common surgical conditions presenting to Weill Bugando Medical Centre in Mwanza, Tanzania, and the areas of greatest need in surgical education. We developed an 8-week teaching schedule for undergraduate students and an electronic database of clinical surgery topics. In addition, we started teaching basic surgical skills in the operating theatre, bridging to an official and recurring workshop through a supporting international surgery organization. The medical and assistant medical officer students reported increased satisfaction with their clinical surgery rotations and mastery of key educational subjects. The initiation of an Essential Surgical Skills workshop through the Canadian Network for International Surgery showed students had improved comfort with basic surgical techniques. Short-term surgical missions may appear to fill a void in the shortage of health care in the developing world. However, we conclude that global health resources are more appropriately used through projects giving ownership to local providers and promoting education as a foundation of development. This results in better coordination among local and visiting providers and greater impact on education and long-term growth of health care capacity.

Les initiatives internationales en ce qui concerne la chirurgie sont de plus en plus axées sur le renforcement des programmes de formation et des systèmes de soins de santé locaux pour consolider les capacités dans ce domaine. L'objectif de ce projet éducatif était d'aider les professionnels de la santé locaux à enrichir le programme de chirurgie d'une nouvelle faculté de médecine et de favoriser ainsi l'atteinte des objectifs et une meilleure participation à long terme à l'échelle locale. En travaillant avec des chirurgiens, des résidents, des étudiants en médecine et de futurs aides-médecins locaux, nous avons recensé les chirurgies les plus fréquentes au Centre médical Weill Bugando à Mwanza à la Tanzanie, et les domaines de la chirurgie où les besoins de formation sont les plus grands. Nous avons mis sur pied un calendrier d'enseignement échelonné sur 8 semaines pour les étudiants et une base de données électronique sur les différents types de chirurgie clinique. Nous avons également commencé à enseigner les techniques chirurgicales de base au bloc opératoire, en parallèle avec un atelier officiel récurrent, grâce au soutien d'une association internationale de chirurgie. Les étudiants en médecine et les futurs aides-médecins se sont dits plus satisfaits de leur stage de chirurgie clinique et de leur maîtrise des principaux enjeux didactiques. Le lancement d'un atelier sur les compétences chirurgicales de base, rendu possible grâce au Réseau canadien pour la chirurgie internationale, a montré que les étudiants se sentent plus à l'aise avec les techniques chirurgicales de base. Les missions chirurgicales de courte durée peuvent sembler combler une lacune dans les pays en développement où les soins de santé sont insuffisants. Toutefois, nous concluons que les ressources en santé internationale sont utilisées de manière plus appropriée dans le cadre de projets qui responsabilisent les fournisseurs de soins locaux et favorisent leur formation comme base du développement. Cela donne lieu à une meilleure coordination entre les professionnels locaux et les coopérants et exerce un impact plus grand sur la formation et la croissance des capacités en matière de soins de santé à long terme.

Survey of care and evaluation of East African burn unit feasibility: an academic burn center exchange.

Weill Cornell Medical College in New York, partnered with Weill Bugando Medical College and Sekou Toure Regional Referral Hospital, in Mwanza, Tanzania, to consider the development of a burn unit there. This institutional partnership provided a unique opportunity to promote sustainable academic exchange and build burn care capacity in the East African region. A Weill Cornell burn surgeon and burn fellow collaborated with the Sekou Toure department of surgery to assess its current burn care capabilities and potential for burn unit development. All aspects of interdisciplinary burn care were reviewed and institutional infrastructure evaluated. Sekou Toure is a 375-bed regional referral center and teaching hospital of Weill Bugando Medical College. In 2010-2011, it admitted 5244 pediatric patients in total; 100 of these patients were burn-injured children (2% of admissions). There was no specific data kept on percentage of body surface burned, degree of burn, length of stay, or complications. No adult, operative, or outpatient burn data were available. There are two operating theaters. Patient's families perform wound care with nursing supervision. Rehabilitation therapists consult as needed. Meals are provided three times daily by a central kitchen. Public health outreach is possible through village-based communication networks. Infrastructure to support the development of a burn care unit exists at Sekou Toure, but needs increased clinical focus, human resource capacity building, and record-keeping to track accurate patient numbers. A multidisciplinary center could improve record-keeping and outcomes, encourage referrals, and facilitate outreach through villages.

Triple assessment as a preoperative diagnostic tool for breast cancer at Bugando Medical Centre in northwestern Tanzania.

The triple assessment in the pre-operative evaluation of breast cancer has been practiced in some hospitals in Tanzania. However, its validity and reliability has not been evaluated in any hospital in the country including the study area. This cross-sectional study was conducted at Bugando Medical Centre in northwestern Tanzania to determine the validity, reliability and applicability of triple assessment as an alternative to conventional open biopsy in the pre-operative diagnosis of breast cancer. A total of 212 female patients aged 35 years and above were studied. All patients underwent clinical evaluation, mammography and fine needle aspiration cytology. Histopathology was done to confirm the diagnosis. One hundred and twenty (56.6%) patients with a median age of 36 years had benign lesions and the remaining ninety-two (43.4%) with a median age of 47 years had breast cancer (P = 0.002). With triple assessment, 92 patients were diagnostic for malignancy and 120 benign, respectively confirmed by histopathology. The Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value and Accuracy were 100.0%. There were no false positive or false negative results. The Kappa statistic for the combination was 1.0 implying excellent agreement with histopathology. The majority of patients (59.9%) underwent triple assessment on the same day with results being available to the patient within 24 to 72 hours. The triple assessment is an accurate and quick method for the evaluation of breast cancer and can be applied as a safe alternative for open biopsy when it is concordant.

Dynamic Bowel Obstruction: Aetiology; Clinical Presentation; Management and Outcome at Bugando Medical Centre; Mwanza; Tanzania

Dynamic bowel obstruction is a common and potentially dangerous surgical emergency with high morbidity and mortality worldwide. No prospective study has been done on this subject in our setting. This study was conducted to describe in our region; the aetiology; clinical presentation; management and outcome of dynamic bowel obstruction. Data were analyzed using SPSS software system. A total of 342 patients were studied. Males outnumbered females by a ratio of 2.1: 1. The median age of patients at presentation was 34 years (range 11 to 78 years). Obstructed hernias (32.7) were the commonest cause of dynamic bowel obstruction. Abdominal pain (100) and vomiting (86.5) were the most frequent presenting symptoms. Thirty-one (9.1) patients were HIV positive. Small bowel was the commonest site of obstruction accounting for 89.2 of cases. Herniorrhaphy was the most frequent surgical procedure performed in 112 (32.7) patients. Surgical site infection (38.8) was the most common post-operative complication and it was significantly associated with HIV positivity and low CD 4+ count (p0.001). The overall median of length of hospital stay was 26 days (range 1 to 72 days). Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p

Skin cancers among Albinos at a University teaching hospital in Northwestern Tanzania: a retrospective review of 64 cases.

BACKGROUND: Skin cancers are a major risk associated with albinism and are thought to be a major cause of death in African albinos. The challenges associated with the care of these patients are numerous and need to be addressed. The aim of this study was to outline the pattern and treatment outcome of skin cancers among albinos treated at our centre and to highlight challenges associated with the care of these patients and proffer solutions for improved outcome. METHODS: This was a retrospective study of all albinos with a histopathological diagnosis of skin cancer seen at Bugando Medical Centre from March 2001 to February 2010. Data collected were analyzed using descriptive statistics. RESULTS: A total of 64 patients were studied. The male to female ratio was 1.5:1. The median age of patients was 30 years. The median duration of illness at presentation was 24 months. The commonest reason for late presentation was financial problem. Head and the neck was the most frequent site afflicted in 46(71.8%) patients. Squamous cell carcinoma was the most common histopathological type in 75% of cases. Surgical operation was the commonest modality of treatment in 60 (93.8%) patients. Radiotherapy was given in 24(37.5%) patients. Twenty-seven (42.2%) of the patients did not complete their treatment due to lack of funds. Local recurrence following surgical treatment was recorded in 6 (30.0%) patients. Only thirty-seven (61.7%) patients were available for follow-up at 6-12 months and the remaining patients were lost to follow-up. CONCLUSIONS: Skin cancers are the most common cancers among albinos in our environment. Albinism and exposure to ultraviolet light appears to be the most important risk factor in the development of these cancers. Late presentation and failure to complete treatment due to financial difficulties and lack of radiotherapy services at our centre are major challenges in the care of these patients. Early institution of preventive measures, early presentation and treatment, and follow-up should be encouraged in this population for better outcome.

Typhoid intestinal perforations at a University teaching hospital in Northwestern Tanzania: A surgical experience of 104 cases in a resource-limited setting.

BACKGROUND: Typhoid intestinal perforation is still prevalent in many developing countries. Despite the advances in the management, the outcome in these patients in resource limited countries is still very poor. This study was to review our experiences on the surgical management of typhoid intestinal perforation and to determine the prognostic factors for mortality in our local setting. METHODS: This was a combined retrospective and prospective study of patients who were operated for typhoid intestinal perforation at Bugando Medical Centre between August 2006 and September 2011. Data collected were analyzed using SPSS computer software version 15. RESULTS: A total of 104 patients were studied representing 8.7% of typhoid fever cases. Males were affected twice more than the females (2.6:1). Their ages ranged from 8 to 76 years with a median age of 18.5 years. The peak age incidence was in the 11-20 years age group. Fever and abdominal pain were the most common presenting symptoms and majority of the patients (80.8%) perforated between within 14 days of illness. Chest and abdominal radiographs revealed pneumoperitonium in 74.7% of cases. Ultrasound showed free peritoneal collection in 85.7% of cases. Nine (10.2%) patients were HIV positive with a median CD4+ count of 261 cells/µl. The perforation-surgery interval was more than 72 hours in 90(86.5%) patients. The majority of patients (84.6%) had single perforations and ileum was the most common part of the bowel affected occurring in 86.2% of cases. Simple closure of the perforations was the most commonly performed procedure accounting for 78.8% of cases. Postoperative complication rate was 39.4% and surgical site infection was the most frequent complication in 55.5% of cases. Mortality rate was 23.1% and it was statistically significantly associated with delayed presentation, inadequate antibiotic treatment prior to admission, shock on admission, HIV positivity, low CD4 count (< 200 cells/µl), high ASA classes (III-V), delayed operation, multiple perforations, severe peritoneal contamination and presence of postoperative complications (P < 0.001). The median overall length of hospital stay was 28 days. CONCLUSION: Typhoid intestinal perforation is still endemic in our setting and carries high morbidity and mortality. This study has attempted to determine the factors that statistically influence mortality in typhoid perforation in our environment. Appropriate measures focusing at these factors are vital in order to deliver optimal care for these patients in this region.

Marjolin's ulcers at a university teaching hospital in Northwestern Tanzania: a retrospective review of 56 cases.

BACKGROUND: Marjolin's ulcer is a rare but highly aggressive squamous cell cancer that is most often associated with chronic burn wounds. Although many individual case reports exist, no comprehensive evaluation of Marjolin's ulcer patients has been conducted in our setting. This study was conducted to describe the clinicopathological presentation and treatment outcome of this condition in our local setting and to identify predictors of outcome. METHODS: This was a retrospective study of histologically confirmed cases of Marjolin's ulcer seen at Bugando Medical Centre over a period of 10-years between January 2001 and December 2010. Data were retrieved from patients' files and analyzed using SPSS computer software version 15.0 RESULTS: A total of 56 patients were studied. Male to female ratio was 2.1:1. Burn scars (89.3%) were the most common causative lesions of Marjolin's ulcer. The mean latent period between original injury and diagnosis of Marjolin's ulcer was 11.34 ± 6.14 years. Only 12.0% of the reported cases were grafted at the time of injury (P < 0.00). Most patients (48.2%) presented between one and five years of onset of illness. The lower limb (42.9%) was the most frequent site for Marjolin's ulcers. The median tumor size at presentation was 8 cm and the vast majority of patients (85.7%) presented with large tumors of ≥ 5 cm in diameter. Lymph node metastasis at the time of diagnosis was recorded in 32.1% of cases and distant metastasis accounted for 26.9% of cases. Squamous cell carcinoma (91.1%) was the most common histopathological type. Wide local excision was the most common surgical procedure performed in 80.8% of cases. Post-operative complication rate was 32.1% of which surgical site infection was the most common complication in 38.9% of patients. Local recurrence was noted in 33.3% of cases who were treated surgically. The mean length of hospital stay for in-patients was 7.9 ± 2.3 days. Mortality rate was 7.1%. According to multivariate logistic regression analysis, stage and grade of the tumor and presence of local recurrence were the main predictors of death (P < 0.001). CONCLUSION: Marjolin's ulcers are not rare in our environment and commonly occur in burn scars that were not skin grafted and were left to heal secondarily. A high index of suspicion is required in the management of chronic non-healing ulcers and all suspected lesions should be biopsed. Early recognition and aggressive treatment of Marjolin's ulcers and close follow-up are urgently needed to improve outcomes in our environment.

Splenic injuries at Bugando Medical Centre in northwestern Tanzania: a tertiary hospital experience.

BACKGROUND: Splenic injuries constitute a continuing diagnostic and therapeutic challenge to the trauma or general surgeons practicing in developing countries where sophisticated imaging facilities are either not available or exorbitantly expensive. The purpose of this review was to describe our own experience in the management of the splenic injuries outlining the aetiological spectrum, injury characteristics and treatment outcome of splenic injuries in our local environment and to identify predictors of outcome among these patients. METHODS: A prospective descriptive study of splenic injury patients was carried out at Bugando Medical Centre in Northwestern Tanzania between March 2009 and February 2011. Statistical data analysis was done using SPSS software version 17.0. RESULTS: A total of 118 patients were studied. The male to female ratio was 6.4:1. Their ages ranged from 8 to 74 years with a median age of 22 years. The modal age group was 21-30 years. The majority of patients (89.8%) had blunt trauma and road traffic accidents (63.6%) were the most frequent cause of injuries. Most patients sustained grade III (39.0%) and IV (38.1%) splenic injuries. Majority of patients (86.4%) were treated operatively with splenectomy (97.1%) being the most frequently performed procedure. Postoperative complications were recorded in 30.5% of cases. The overall length of hospital stay (LOS) ranged from 1 day to 120 days with a median of 18 days. Mortality rate was 19.5%. Patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with associated injuries stayed longer in the hospital (P < 0.001), whereas age of the patient, associated injuries, trauma scores (KTS II), grade of splenic injuries, admission systolic blood pressure ≤ 90 mmHg, estimated blood loss > 2000 mls, HIV infection with CD4 ≤ 200 cells/µl and presence of postoperative complications were significantly associated with mortality (P < 0.001). CONCLUSION: Trauma resulting from road traffic accidents (RTAs) remains the most common cause of splenic injuries in our setting. Most of the splenic injuries were Grade III & IV and splenectomy was performed in majority of the cases. Non-operative management can be adopted in patients with blunt isolated and low grade splenic injuries but operative management is still indispensable in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of splenic injuries in our centre.

Stage at diagnosis, clinicopathological and treatment patterns of breast cancer at Bugando Medical Centre in north-western Tanzania.

Breast cancer, although reported to be the commonest female malignancy worldwide has not been extensively studied in north-western Tanzania. The aim of this retrospective review was to describe in our setting, the stage at diagnosis, clinicopathological and treatment patterns among patients with breast cancer. Data were analyzed using SPSS software system. A total of 384 patients were studied. The median age was 45 years (range 21 to 78 years). The male to female ratio was 1: 46.8. Most of the patients were premenopausal (63.8%) and presented late with advanced breast cancer disease. Majority of patients (63.0%) presented with stage III disease. Lymph node and distant metastasis at the time of diagnosis was reported in 70.8% and 21.4% of patients, respectively. Invasive ductal carcinoma (91.7%) was the most frequent histopathological type and most patients (63.8%) had poorly differentiated tumour. Patients with tumour size greater than 6cm had significantly high rate of lymph node metastasis (P=0.001) and presence of necrosis within the tumour (P=0.012) compared to patients with tumour size less than 6cm in diameter. Patients younger than 45 years had significantly high rate of lymph node metastasis compared to the patients above this age (P=0.0 11). Mastectomy was the main modality of treatment that was used in 99.5% of the patients. Adjuvant chemotherapy and radiotherapy was reported in 44.8% and 11.7% of patients, respectively. Hormonal therapy (tamoxifen) was given postoperatively to all patients. The overall five-year survival rate was 21.8%. The age of patient at diagnosis, stage of disease, extent of lymph node involvement and histological grade were found to be independent predictors of overall survival rate (P<0.001). Local recurrence was 17.7% and it was significantly related to the stage of disease (P=0.003) and non-adherent to adjuvant therapy (P=0.021). Breast cancer patients in this region are relatively young premenopausal women and mostly present late with advanced stage and high rate of lymph node metastasis. There is need to improve public enlightenment of breast cancer and set up screening centres to encourage early presentations.

Pattern of childhood burn injuries and their management outcome at Bugando Medical Centre in Northwestern Tanzania.

BACKGROUND: Burn injuries constitute a major public health problem and are the leading cause of childhood morbidity and mortality worldwide. There is paucity of published data on childhood burn injuries in Tanzania, particularly the study area. This study was conducted to describe the pattern of childhood burn injuries in our local setting and to evaluate their management outcome. METHODS: A cross sectional study was conducted at Bugando Medical Centre (in Northwestern Tanzania) over a 3-year period from January 2008 to December 2010. Data was collected using a pre-tested coded questionnaire and statistical analyses performed using SPSS software version 15.0. RESULTS: A total of 342 burned children were studied. Males were mainly affected. Children aged = 2 were the majority accounting for 45.9% of cases. Intentional burn injuries due to child abuse were reported in 2.9% of cases. Scald was the most common type of burns (56.1%). The trunk was the most commonly involved body region (57.3%). Majority of patients (48.0%) sustained superficial burns. Eight (2.3%) patients were HIV positive. Most patients (89.8%) presented to the hospital later than 24 h. The rate of burn wound infection on admission and on 10th day were 32.4% and 39.8% respectively.Staphylococcus aureus were more common on admission wound swabs, with Pseudomonas aeruginosa becoming more evident after 10th day. MRSA was detected in 19.2% of Staphylococcus aureus. Conservative treatment was performed in 87.1% of cases. Surgical treatment mainly skin grafting (65.9%) was performed in 44 (12.9%) of patients. The overall average of the length of hospital stay (LOS) was 22.12 ± 16.62 days. Mortality rate was 11.7%. Using multivariate logistic regression analysis; age of the patient, type of burn, delayed presentation, clothing ignition, %TBSA and severity of burn were found to be significantly associated with LOS (P < 0.001), whereas mortality rate was found to be independently and significantly related to the age of the patient, type of burn, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (P < 0.001). CONCLUSION: Childhood burn injuries still remain a menace in our environment with virtually unacceptable high morbidity and mortality. There is need for critical appraisal of the preventive measures and management principles currently being practiced.

HIV, appendectomy and postoperative complications at a reference hospital in Northwest Tanzania: cross-sectional study.

BACKGROUND: Appendicitis is a frequent surgical emergency worldwide. The present study was conducted to determine the prevalence of HIV, and the association of infection with clinical, intraoperative and histological findings and outcome, among patients with appendicitis. METHODS: We performed a cross sectional study at Weill-Bugando Medical Centre in northwest Tanzania. In total, 199 patients undergoing appendectomy were included. Demographic characteristics of patients, clinical features, laboratory, intraoperative and histopathological findings, and HIV serostatus were recorded. RESULTS: In total, 26/199 (13.1%) were HIV-seropositive. The HIV-positive population was significantly older (mean age: 38.4 years) than the HIV-negative population (25.3 years; p < 0.001). Leukocytosis was present in 87% of seronegative patients, as compared to 34% in seropositive patients (p = 0.0001), and peritonitis was significantly more frequent among HIV-positives (31% vs. 2%; p < 0.001). The mean (SD) length of hospital stay was significantly longer in HIV-positives (7.12 ± 2.94 days vs. 4.02 ± 1.14 days; p < 0.001); 11.5% of HIV patients developed surgical site infections, as compared to 0.6% in the HIV-negative group (p = 0.004). CONCLUSION: HIV infections are common among patients with appendicitis in Tanzania, and are associated with severe morbidity, postoperative complications and longer hospital stays. Early diagnosis of appendicitis and prompt appendectomy are crucial in areas with high prevalence of HIV infection. Routine pre-test counseling and HIV screening for appendicitis patients is recommended to detect early cases who may benefit from HAART.

Schistosomal peritonitis secondary to perforated appendicitis

In Tanzania, Schistosoma mansoni is endemic and causes intestinal schistosomiasis which affects various internal organs. However, worldwide there have been very few reports of cases of peritonitis due to schistosomal appendicitis. Here we report a rare case of schistosomal appendicitis with peritonitis in a 33 year-old male patient who recovered quickly after surgery.

Schistosomal peritonitis secondary to perforated appendicitis.

In Tanzania, Schistosoma mansoni is endemic and causes intestinal schistosomiasis which affects various internal organs. However, worldwide there have been very few reports of cases of peritonitis due to schistosomal appendicitis. Here we report a rare case of schistosomal appendicitis with peritonitis in a 33 year-old male patient who recovered quickly after surgery.