A Digitally Driven Fabrication Approach to Allow Affordable On-Site Manufacture of a Novel Upper Gastroscope Handle
JH Chandler1, M Chauhan1, N Garbin2, V Subramanian2, KL Obstein3,4 and P Valdastri1
1School of Electronic and Electrical Engineering, University of Leeds, UK
2Leeds Institute of Medical Research at St. James’s, University of Leeds, UK
3Mechanical Engineering Department, Vanderbilt University, United States
4Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Abstract
Aim: Previous research has led to the development of an affordable, dual-continuum gastroscope for deployment in low/middle-income countries. The device couples a disposable parallel bellows actuator tip with a reusable multi-backbone ‘snake-like’ handle. Although comparably low-cost and intuitive to operate, fabrication of the current handle design is dependent on bespoke parts, only offered through specialist manufacturing equipment. The aim of this study was to develop more practicable handle designs suitable for on-site fabrication using standard rapid prototyping equipment.
Methods: A full review of the existing design and fabrication pathway was undertaken to identify the key limiting components. Two redesigns were subsequently proposed; considering the exclusive use of 3D printing and laser cutting respectively. Designs were fabricated, assembled and evaluated in terms of cost, fabrication speed and achieved functionality.
Results: For the 3D-printed and laser cut designs, the cost of handle fabrication was reduced by 35% and 52% respectively. The laser cut design also outperformed 3D-printing in terms of speed of fabrication and assembly, durability and achieved functionality.
Conclusions: On-site fabrication of reusable handle parts has the potential to reduce reliance on supply chains while facilitating rapid repair. Through reconsidering the design and fabrication methods used to produce the dual continuum gastroscope handle, it has been possible to dramatically reduce financial and logistical overhead associated with its production. Although the presented laser cut design outperforms the 3D-printed design, the latter may be more practicable due to the wider use and lower capital cost of the associated fabrication equipment.
A Qualitative Study on Community Healthcare Workers’ Views on Post-Partum Depression in Pune, India: Risk Factors, Health Outcomes, Barriers and Improvements
YZ Zhou and M Das
University of Leeds, UK
Abstract
Aim: Explore community healthcare workers’ views of Post-Partum Depression (PPD) in Pune, India: risk factors, health outcomes, barriers and improvements.
Methods: In-depth, semi-structured interviews and focus groups were conducted with Community Health Workers in Pune. Consent was provided for participation and the audio recording of interviews and focus groups. Data was transcribed and thematically analysed, and the University of Leeds granted ethical approval.
Results: There are many risk factors which increase women’s risk of developing PPD. The most commonly mentioned risk factor was gender bias. Negative health outcomes are linked with PPD; children are affected as well as women. Barriers preventing women with PPD seeking healthcare, result in women with PPD remaining undiagnosed. Barriers include a lack of trained healthcare professionals and resources, like a screening tool for PPD. This led to findings of improvements that can be made in the health system and society to facilitate women with PPD to receive healthcare.
Conclusion: PPD affects how women care for themselves and their children. There are many barriers that prevent women with PPD from seeking healthcare. Addressing these barriers is required for women with PPD to seek the appropriate management for their health to improve. In order to tackle the increasing prevalence of PPD in India, improvements in India’s health system, including development of a screening tool for PPD need to be made.
A study on the prevalence of trauma cases on account of “boda boda” accidents admitted at Meru Level 5 referral hospital in Kenya
MN Sekyi-Djan
University of Oxford, Oxford Global Surgery Group, UK
Abstract
Aim: “Boda boda” is the local name for motorcycle, derived from the form of transport commonly used at the border between Kenya and Uganda. It is a growing means of quick and affordable transport within Kenya. The speed and unconventional routes that these motorcycles take contribute greatly to road traffic accidents. This retrospective cross-sectional study reports the prevalence of trauma cases and patterns of injury owing to “boda boda” accidents, with the goal of supporting policy-making decisions to improve road safety.
Methods: Data was obtained from records of trauma cases that had been admitted at Meru Hospital over a 5-month period (October 2018–February 2019).
Results: There was a total of 139 cases and 61 (44%) of these were due to “boda boda” accidents. The majority of patients were motorcyclists (69%), followed by pedestrians (20%) and lastly passengers (11%). The average age was 33years. The most common mechanism of accident was found to be “boda boda” versus vehicles (46%). The most common injuries sustained were mild head injury (49%) followed by moderate head injury (21.3%) and fractures (13%).
Conclusions: The findings highlight the need for firmer regulations and education regarding safety especially helmet use given the commonest injuries sustained, and perhaps a discussion on controlling the importation and licensing of these motorcycles.
Betel Leaves as an Alternative Method of Enterostomy Management in Children
S Parepalli, R Khundkar, T Banu and K Lakhoo
University of Oxford, UK
Abstract
Aim: Stoma constructions are common procedures in paediatric surgery, necessitating the production of viable ostomy bags, an inaccessible luxury in some low-middle-income-countries (LMICs); commercial bags are expensive and often unavailable in appropriate sizes. Alternatives include old clothing, nappies, and food wrappers, associated with high rates of peristomal skin complications. The use of betel leaves, as viable and cost-effective stoma bags, was assessed.
Methods: A literature review assessing the development of skin complications between commercial stoma bags, LMICs alternatives, and the betel leaf alternative was conducted. The search terms ‘betel leaves’ and ‘enterostomy OR stoma’ were entered in Google Scholar. Descriptive literature searches assessed pragmatic factors between betel leaf and commercial bags, including cost, availability, ease of use, reusability and efficiency in collecting bowel fluid.
Results: The search strategy found 3 prospective studies. Study heterogeneity was too high to permit meta-analysis, so results are presented individually. Peristomal excoriations occurred in 2.6%–20.9%, of patients using the betel leaf alternative, compared to 100% of patients using LMICs ostomy alternatives and 21.5%–40.7% of patients using commercial bags. When comparing the betel leave alternative to commercial ostomies, there were no incidences of allergic dermatitis (0% vs 6.3%–18.8%) and similar mucosal ulceration rates (8.1% vs 7.7%). It was roughly 5USD cheaper per week, more prevalent, similarly skill-intensive, re-usable, and equally able to collect bowel fluid.
Conclusion: Betel leaves have the potential to be helpful to paediatric patients in developing countries, by providing an accessible alternative to commercially available ostomy bags and reducing postoperative complications.
Collaborative approach to re-design of a lift device for Gas Insufflation-Less Laparoscopic Surgery (GILLS) in Low and Middle-Income Countries (LMICs)
MM Webb1, P Bridges2, N Aruparayil1, L Bains3, A Mishra3, J Gnanaraj, A Quyn1, R Hall2, and P Culmer1
1NIHR Global Health Research Group – Surgical Technologies, University of Leeds, UK
2Pd-m International Ltd
3Maulana Azad Medical College, New Delhi
4Karunya University, Coimbatore, India
Abstract
Aim: Our aim was to address current LMIC user limitations of a GILLS lift device for laparoscopic abdominal surgery, using a collaborative design approach with LMIC partners to develop a next-generation device.
Methods: To investigate device limitations and areas for improvement, primary research was conducted in India. Experts in GILLS technique gave informal feedback during four surgical demonstrations, ten individual interviews and a group discussion. These were documented in video and questionnaire formats.
To generate solutions, an interdisciplinary team of engineers, designers and surgeons from the UK and India convened for two design workshops. In the first, functional analysis of the GILLS system was conducted to prioritise and parametrise clinical and usability requirements and steer the design direction. Attendees broke the device down into modular components and generated concepts. In the second, a twin-jointed and a telescopic system were compared for usability, operative obstruction, cost, manufacturing feasibility and robustness.
Results: The study in India highlighted issues with device portability, repair, operative vision, time-consuming sterilisation and complex technical operation.
Collaboration between partners resulted in a novel, LMIC-appropriate and radically simplified design. Solely surgeon-operated during the procedure, it allows intuitive control of abdominal wall lift and load. Its telescopic arm enables it to meet aeroplane baggage restrictions and autoclave size requirements for rural hospitals, without compromise to surgical function.
Conclusion: The study highlights the value of a collaborative, interdisciplinary approach to designing medical devices for LMICs. The next-generation GILLS device addresses major limitations of current systems to support its wider adoption in LMICs.
Developing Low-Cost Techniques to Improve the use of Ilizarov Circular Frame Fixators for Tibial Fractures in Low and Middle-Income Countries
U Anyamele
1
J Godfrey2, E Nerwich2, B Saravanan3, W Bolton4, P Culmerand Stewart5
1School of Medicine, University of Leeds, UK
2School of Mechanical Engineering, University of Leeds, UK
3PSG College of Technology, Coimbatore, India
4NIHR Global Health Research Group – Surgical Technologies, University of Leeds
5School of Medical Engineering, University of Leeds, UK
Abstract
Aims: Worldwide, approximately 90% of trauma-related deaths occur in low and middle-income countries (LMICs) – many on account of severe fractures.1 Unfortunately, fracture management is challenging in this context and many people receive little or no treatment.
Ilizarov frames could be highly beneficial in LMICs; however their cost is currently prohibitive. This project explores possible improvements to these frames which reduce cost using frugal engineering techniques.2
Methods: Tensile testing of standard wires and low-cost bicycle spokes was conducted to evaluate the capability of a novel spoke clamping system to resist spokes slipping off the frame, maintaining ideal tension for fracture healing.3 Further bench tests investigated the relationship between wire tension and frequency response as measured by a low-cost microphone, with the aim of developing a robust and clinically-relevant means of measuring wire tension.
Results: Wire slippage tests highlighted the inability of current fixation method to maintain tension. The novel bicycle spokes and nipple fixation method eliminated slippage while providing an easier means of tensioning the spoke through twisting the spoke nipples. Frequency response and tension showed a consistent linear relationship that could be developed with further method refinement and testing.
Conclusions: Bicycle spokes are a viable, cheaper and more robust alternative to Ilizarov wires. Low-cost microphones could potentially assess tension and healing in the future. Motion tracking technology can be used to assess frame deformation in bench models. These methods are relevant to National Health Service and LMIC populations and will be validated in cadaver and live human studies.
Drivers of antibiotic resistance in Uganda: the role of drug sellers
R Allan
University of Leeds, UK
Abstract
Aim: Antibiotic resistance is a global health concern, particularly for lower income countries. Given that unregulated drug sellers are dominant health care providers in Uganda, it is important to examine their role in the overuse of antibiotics and why they are the preferred service provider.
Methods: This cross-sectional study data was collected through fourteen semi-structured interviews with drug sellers from community pharmacies during May 2019, in Kabale, Uganda. Thematic analysis was then conducted on transcriptions.
Results: Most respondents understood how rationally to use antibiotics but would still sell incomplete doses or unnecessary antibiotics owing to pressure arising from a customer’s financial concerns. Lack of training may contribute to this. Tests and examinations did not frequently take place. Many drug sellers did not understand how antibiotic resistance develops nor its consequences. It appeared that drug sellers were popular with all types of people. Customers choose pharmacies based upon affordability and customer-seller relationships. Regularly customers requested antibiotics for animals but most drug sellers refused through insufficient knowledge.
Conclusion: Interviews provided evidence that irrational use of antibiotics in Kabale is common. In order to halt the development of antibiotic resistance, drug sellers and customers require further education about antibiotics, to improve their rational use. It is necessary also to develop a system that reduces the cost of antibiotics so they may be affordable to all.
EcoClave™ – the solution to the global surgical instrument sterilisation problem?
JAW Dalton1 and TR Beacon2
1Specialty Registrar in Obstetrics and Gynaecology, West Yorkshire, UK
2Medical Aid International, UK
Abstract
Aims: Surgical site infections affect as many as one third of surgical patients in LMICs.1 Poor sterility of surgical instruments may contribute to this problem. The EcoClave™ is a 40 L wood-fuelled autoclave which was designed to be a simple, affordable and highly effective sterilisation solution for low-resource environments. We had two aims:
1. Explore the problems faced with sterilisation of surgical instruments in rural Uganda.
2. Explore experiences of using the EcoClave™ in rural settings in Uganda.
Methods: The above aims were addressed with two separate methods:
1. Aim 1 was addressed by distributing a qualitative and quantitative questionnaire amongst 30 delegates at a Primary Trauma Course (PTC) in Arua, Uganda.
2. Aim 2 was addressed by distributing a questionnaire to staff at three EcoClave™ pilot sites (two health centres and one hospital) in rural Uganda.
Results: 1. Sterility questionnaire: responses were received from 26/30 PTC delegates. Only 15% were able to consistently use their autoclave when required. 68% were using autoclaves with a capacity of <20 L. The main barriers to effective sterilisation noted were electricity cut-offs and the inability to repair and maintain electric autoclaves.
2. EcoClave™ questionnaire: responses were received from 3/3 centres. Qualitative feedback regarding the EcoClave™ was positive from all pilot centres:
“The size and capacity to take in a big number of equipments all at once is really helping out achieve sterilization in a one step attempt.” [Health Centre]
“Before the EcoClave installation, we used to sink the used instruments in jik [sodium hydrochloride bleach] immediately after use, then hand wash with soap and plenty of water… There was no timing and sterility was always assumed… Cleaning and sterilizing are now effective.” [Health Centre]
“The great advantage of the Ecoclave is that it can be used to sterilize instruments, etc., even when there is a prolonged power cut.” [District hospital]
Conclusion: Our data suggest autoclaves cause frequent problems in LMIC settings. The EcoClave™ offers a potential solution to the problem of sterilisation in such settings.
Declaration of Interest
TR Beacon is the Chief Executive Officer of Medical Aid International, which markets and distributes the EcoClave™ autoclave.
Establishing a Sustainable Cervical Screening Service in West Uganda
C Howell1, V Kaul2, J Auma3, D Gashuga3, A Ndawula3 and L Ackers
3 NHS Foundation Trust, UK
2The Mid Yorkshire Hospitals NHS Trust, UK
3Knowledge for Change, UK
Abstract
Aim: Cervical cancer is the leading cause of cancer death in women in Uganda, and rates are currently rising. Lack of access to quality cervical screening services is a key reason why >80% cases are identified too late for treatment. Knowledge for Change aimed to collaborate with local staff at Kagote and Bukuuku Health Centres in establishing a unique service for patients.
Methods: Using two new technologies- the Enhanced Visual Assessment (EVA) system, and the ‘Liger’ hand-held thermocoagulator, alongside traditional visual inspection with acetic acid, we have created a training programme for healthcare workers, allowing them to provide screening with assisted mentorship and back-up advice from the UK team. Training in Uganda has consisted of plenaries, communication skills breakout sessions, hands on simulation using both devices on shoebox models as well as clinical sessions at the Health Centres and a local prison community outreach.
Results & Conclusion: Since commencement in 2018, over 550 patients have been screened. 28 Ugandan Health Care Workers and 5 Village Health Team members have been trained. Every two weeks, patients are discussed and reports are sent between Uganda and the UK for treatment advice, knowledge sharing and discussion over individual cases using a secure portal facilitated by MobileODT. Community sensitisation work by way of door-to-door surveys and promotion of the service has also been undertaken. To encourage sustainability, training the local trainer activities are now underway, as well as opportunities for members of the team to undertake Commonwealth Fellowships in the UK in cervical screening education.
Evaluating the usability of a low-cost laparoscopic simulator for training medical students and surgical trainees in low- and middle-income countries
Aruparayil Chauhan1, R Sawhney2, C Franco Da Silva2, W Bolton1, J Burke3, A Mishra4, J Gnanaraj5, D Jayne1 and P Valdastri1
1NIHR Global Health Research Group – Surgical Technologies, University of Leeds, UK
2School of Medicine, University of Leeds
3Leeds Institute of Medical Research at St James’s, University of Leeds
4Maulana Azad Medical College, New Delhi
5Karunya University, Coimbatore
Abstract
Aim: Laparoscopic trainers are used to develop hands-on skills in trainee surgeons by emulating technical methods of laparoscopic surgery. Although innumerable trainers are available commercially; they are often not widely affordable in low- and middle-income countries (LMICs). In these settings, lack of trained personnel adds to the surgical burden of disease, justifying the need for inexpensive trainers.
Methods: We propose an inexpensive laparoscopic simulator (Lap-Pack) with: (i) Endoscopic camera, (ii) Instrumental ports, (iii) Suture scale, and (iv) Mounting plate built with strong, corrugated plastic with a lightweight and portable design. Designed for easy assembly and compatibility with smart devices, Lap-Pack is available in two versions, with and without endoscopic camera, costing approximately USD50 and USD20 respectively.
Lap-Pack was evaluated in a usability study conducted at Maulana Azad Medical College, New Delhi (India) in July, 2019. 10 senior surgeons, 11 junior trainees and 12 medical students completed two tasks (peg transfer and precision cutting), scoring Lap-Pack in a 25-point questionnaire.
Results: All participants scored Lap-Pack on several criteria from a score of 1 (low) to 7 (high). Lap-Pack’s weight, mobility, quality of image and colour of image scored highest, with respective standard deviations highlighted in Table 1 below:
Conclusion: Lap-Pack is a suitable solution for providing low-cost laparoscopic skills training to surgeons and medical students alike. Its ease of assembly, portability and versatility shows promise of increasing access to training opportunities especially in LMICs.
All authors declare no commercial interests in the LapPack trainer used in this study.
Exploring Healthcare Professionals’ experiences and beliefs of cancer, and opportunities for cancer identification in an Anti-Retroviral Therapy Clinic at the Good Shepherd Hospital, Eswatini
C Eggleston and N Putnis
University of Leeds, UK
Abstract
Aim: Our study aimed to gain an insight into the experiences, beliefs and understanding of cancer among healthcare professionals (HCP) at the Good Shepherd Hospital (GSH), Eswatini, and to suggest feasible solutions to avoid missing cancer symptoms at an Anti-retroviral Therapy (ART) clinic.
Methods: Ethical approval was obtained from the University of Leeds (fmhrec-18-0.1) and Eswatini’s National Health Research Review Board (NHRRB) (SHR08112/2019). Ten semi-structured interviews were conducted. Purposive sampling was used to select participants. Informed written consent was obtained at the start of interviews. Interviews were audio-recorded; transcribed and analysed thematically.
Results: Lack of knowledge and absence of screening tools were the most commonly reported barriers to identifying symptoms of cancer in ART clinics. HCPs blamed patients’ low awareness and fear of cancer as the major barrier to identifying symptoms. HCPs’ experience of cancer was with end-stage disease, leading participants to view it as a palliative disease. Development of screening tools to help HCPs identify ‘red flag’ symptoms and prompt further investigation, and national education programmes, were the favoured methods of improving symptom recognition.
Conclusion: Cancer was believed to be an end-of life disease among participants, attributable to a lack of knowledge and infrastructure, preventing cancer diagnosis in its early stages. ART clinics provide a unique opportunity to identify potential cancer in a high risk group at an earlier stage, as patients regularly attend ART clinics, thus, overriding late healthcare seeking behaviour. To maximise this opportunity, screening tools need developing, the referral system strengthening and the population educating to improve clinical suspicion, referral and awareness of cancer.
Exploring the need for a structured laparoscopic surgical curriculum: The experiences of rural Indian surgeons
E Wilkinson1, N Aruparayil1, A Virk1, J Gnanaraj2 and D Jayne1
1NIHR Global Health Research Group – Surgical Technologies, University of Leeds
2Karunya University, Coimbatore, India
Abstract
Aim: To determine if there is need for development of a structured laparoscopic surgical curriculum for rural Indian surgeons, through exploring their training experiences and perspectives.
Methods: Eleven surgeons with experience practising laparoscopy in rural India were recruited through a regional surgical leader, through purposive and convenience sampling. Participants gave informed consent to take part in semi-structured interviews, which were audio-recorded and transcribed. Thematic content analysis was then carried out. Ethical approval was granted by the University of Leeds and the Maulana Azad Medical College, New Delhi.
Results: Although exposure to laparoscopy during postgraduate training was common, training experiences were inconsistent and informal. There is high demand for access to laparoscopic training for rural surgeons, and need for development of a structured curriculum, for the benefits of better education and a formal qualification. Preferences are for inclusion in the Diploma in National Board Rural Surgery curriculum, incorporating observation and assistance of live surgery, box trainers, and objective assessment.
Conclusion: Laparoscopic training experiences and accessibility is consistent with that recorded in literature from similar settings. A widespread qualitative study into desirable features of a curriculum is needed. Universal demand for laparoscopic training opportunities for rural surgeons means government review and investment has been recommended.
Facilitating factors and barriers to health facility delivery in Nawalparasi district, Nepal: a qualitative study of the perspectives of mothers and health workers
F Dimambro-Denson
University of Sheffield, UK
Abstract
Aim: To gain an understanding of the factors which influence why women give birth at health facilities in Nawalparasi district, Nepal, to propose recommendations to increase deliveries at birthing centres.
Methods: Nineteen qualitative semi-structured interviews were conducted using an interpreter. Five auxiliary nurse midwives, seven female community health volunteers and seven mothers were interviewed at five birthing centres. Thematic analysis was used.
Results: The main factors identified in a decision to give birth at a health facility were counselling, safety of delivering at health facilities, availability of services and incentives. Barriers identified, although not applicable to all of these mothers, included lack of education, tradition, inaccessibility and financial problems.
Conclusion: This study has identified key factors influencing a woman to deliver at a health facility. Similarities were found with previous studies from Nepal. Four recommendations were proposed based on these findings:
• Increase number of birthing centres across Nepal
• Provide an accessible ambulance service
• Increase attendance of mother groups by providing snacks as incentives
• Conduct further research on factors influencing location of delivery across the entire Terai region including mothers who delivered at home
Geographic and specialty use trends in ultrasound use in LMICs: A systematic review
KA Stewart1, SM Navarro2, 3, 4
A Dube5, S Kambala2, G Tan2, R Poondla2, K Barbour1 and C Lavy4
1Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN, USA
2Department of Surgery, Baylor College of Medicine, Houston, USA
3Said Business School, University of Oxford, Oxford, UK
4Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford University, Oxford, UK
5National University of Science and Technology, Bulawayo, Zimbabwe
Abstract
Aims: Evidence on recent trends on the impact and cost-benefit of ultrasound in resource-constrained settings is limited. This study conducted a systematic review to determine the recent trends in the utility and applicability of ultrasound use in LMICs. This included characterizing and evaluating trends in (1) the geographic and specialty specific use of ultrasound in LMICs, (2) the innovative applications and the accompanying research findings, and (3) the development of associated educational and training programs.
Methods: The electronic databases Medline OVID, EMBASE, and Cochrane were searched from 2010 to 2018, for studies available in English, French, and Spanish. Commentaries, opinion articles, reviews and book chapters were excluded. Two categories were created, one for reported applications of ultrasound use in LMICs and one for original ultrasound studies.
Results: A total of 6,276 articles were identified and screened, 4,563 studies were included for final review. 332 studies contained original or novel applications of ultrasound use in LMICs. Nearly 70% of studies involved ultrasound usage originating from Southeast Asia and Sub-Saharan Africa, with the region with the highest number innovative ultrasound use in Sub-Saharan Africa. Educational studies, global collaborations, and funded studies were a smaller subset of overall ultrasound research. Our findings are limited by the lack of higher quality evidence and limited number of randomized clinical trials reported.
Conclusion: Our systematic literature review of ultrasound use in LMICs demonstrates the growing utilization of this relatively low-cost, portable imaging technology in low resource settings.
GHEMS: Global Health Education in UK Medical Schools
S Bandyopadhyay, T Shortland, SW Wadanamby, HS Thomas, B Gurung, M Akhbari, I Trout, R Patel, K Sharma, JE Fitzgerald and AD Smith
On behalf of the InciSioN UK Collaborative, UK
Abstract
Aim: Global health (GH) encompasses the study, research and practice of health promotion and equity worldwide. The General Medical Council (GMC) have outlined GH competencies essential to UK medical school curricula. However, paucity of evidence demonstrates that medical school curricula are deficient in GMC prescribed GH learning outcomes. This multicentre study aims to delineate the breadth of global medicine teaching within UK medical schools.
Methods: This national, multi-centre study will include timetables detailing teaching at all UK medical schools for the academic year 2018/19. Collaborators at each centre will independently code all timetabled GH learning events (compulsory, optional or pre-elective), conforming to a pre-devised standard framework enabling the description of teaching events relating to course year, duration and teaching format and content. Quantitative and qualitative data thus gathered will be analysed using descriptive statistics and thematic analysis respectively. Krippendorff’s α-coefficient will measure the level of agreement between different collaborator’s datasets at the same centre.
Results: This is the first study to define the extent and characteristics of GH education within UK medical school curricula and capture differences in the teaching provided on various GH learning outcomes between schools.
Conclusions: If this study depicts national discrepancies in teaching, it will place the onus on medical schools and the GMC to provide standardised and adequate GH education within undergraduate and graduate entry medical curriculum. To accomplish this, the study will also identify currently scheduled teaching events at each medical school that could incorporate material related to mandatory GH learning outcomes.
Global Surgery Audit of Paediatric Surgery Provision at Northampton General Hospital
J Moran, K Ford and K Lakhoo
University of Oxford, UK
Abstract
Aim: The Optimal Resources for Children’s Surgical Care (OReCS) document was published by the Global Initiative for Children’s Surgery (GICS) in order to advance global surgical care for children. It outlines national strategies that can reform healthcare systems to improve paediatric surgery, the necessary resources required for effective surgical care and the procedures that are expected to be performed at each hospital level. Our aim is to show that the OReCS document can be used to evaluate the level of children’s surgical care at a typical UK district general hospital.
Methods: We undertook a retrospective audit of Northampton General Hospital’s (NGH) paediatric operating room data to tally the number and type of paediatric procedures performed at NGH over 2 years. The operations performed were then compared to the OReCS document to ascertain the level at which each surgical speciality performed.
Results: 8643 paediatric procedures were performed at NGH from 01/01/2016 to 31/12/2017. The hospital was compliant for 1st-level hospital status for all specialities, 2nd-level hospital status for ENT, plastic, orthopaedic, maxillofacial surgery, gynaecological and urological surgery and 3rd-level hospital status in ophthalmology.
Conclusion: This pilot study shows that the OReCS document can be used to evaluate the level of paediatric surgical services a typical 1st-level hospital can provide. Collaborative projects, such as OXPLORE, will facilitate the co-ordination of paediatric surgery provision nationally.
How effective is smartphone-based fundoscopy in identifying diabetic retinopathy?
J Martin and R Khundkar and N Peter
University of Oxford Global Surgery Group, UK
Abstract
Aim: To assess the evidence base for the use of smartphone-based fundoscopy in screening for diabetic retinopathy (DR) and to discuss whether these techniques could be used to increase access to DR screening programmes in low and lower-middle income countries.
Methods: Several studies looking at the sensitivity and specificity of smartphone-based fundoscopy compared to conventional methods of screening were assessed. Various commercially available adaptors enabling smartphone-based fundoscopy were included.
Results: In studies testing commercially available adaptors the sensitivity ranged from 75–94.3% and the specificity ranged from 89.1–100% when used for screening for diabetic retinopathy, as compared to conventional techniques.
Conclusion: There are several barriers to annual screening in low and lower-middle income countries: limited numbers of ophthalmologists in many regions, distance to clinics and costs (including indirect costs like transport) all reduce the accessibility of care. Smartphone-based fundoscopy has the potential to overcome many of the challenges of screening programmes in resource-poor settings and remote areas. The adaptors cost as little as £180, do not require a constant power source and require little training to be used effectively. The images could be taken in remote locations and sent to medical centres to increase the throughput of screening programmes. With future improvements in both phone cameras and the adaptors the sensitivity and specificity could be increased even further, increasing the attractiveness of smartphone-based screening programmes.
Improving Maternal Mortality in Sub-Saharan Africa with mHealth
S Roche, S Nagraj, R Khundkar
University of Oxford, UK
Abstract
Aim: Maternal mortality following Caesarean section is 50 times higher for mothers in Africa than in high-income countries. Our aim was to identify the main factors influencing maternal outcomes, and to investigate how we could use mHealth in resource-poor environments to improve maternal outcomes.
Methods: A comprehensive search of PubMed and the grey literature was performed to identify original evidence of mHealth interventions that had improved maternal mortality in sub-Saharan Africa. We used the following search terms (mobile phone OR mHealth) AND (pregnancy OR maternal) AND Africa. A total of 206 papers were identified, of which 13 were eligible for our review.
Results: Three important factors influencing maternal outcomes were identified – poor antenatal care attendance, delayed hospital presentation and unidentified high risk pregnancies. For each, evidence for the use of mHealth was found. Antenatal care attendance increases with the sending of pregnancy specific text or voice messages, sent to the mobile phones of pregnant women. More mothers give birth in hospital when their phones are used to receive mobile transport vouchers. High risk pregnancy screening can be made more accessible with the use of portable ultrasound devices and the training of midwives.
Conclusion: mHealth can be used in sub-Saharan Africa to improve maternal outcomes. By utilising existing and upcoming technology it is hoped we will begin to see maternal mortality rates fall. However, there is clearly an unmet need for a centralised, evidence-based approach to mHealth; it is hoped that in the future, we will see these technologies used synergistically.
Incidence, Risk Factors Assessment and Prevention of Pin-Tract Infection of External Fixators among Great March of Return Patients in the Gaza-Strip, Palestine
NM Abu Jamie1, IT Elamassie1, NJ Asfa1, MS Alastal1, YM Alaklok1, MA Ghuniem2, FN Naim2 and B Bottcher2
1Internship doctor at Palestinian Ministry of Health, Palestine
2Islamic University of Gaza, Palestine
Abstract
Aim: Since March 2018, 16027 patients were referred to hospitals with limb injuries sustained during protests at the border fence in the Gaza Strip, called the Great March of Return, including 2232 upper and 7731 lower limb injury. This study examined the incidence of pin-tract infections and evaluated their most common organisms.
Methods: This cross-sectional descriptive study used a convenience sample, consisting of 224 patients injured in the Great March of Return protests, who were treated with external fixators for gunshot wounds. First, a face-to-face interview was conducted with patients who came to the follow-up centres. Secondly medical records were reviewed in the hospital where patients underwent surgery. Logistic regression analysis was performed to identify impact of variables, such as duration between injury and external fixator placement, use of prophylactic antibiotics and smoking, on pin-site infections.
Results: The pin-tract infection rate was 51.3% (n = 115/224) with 42.6% (n = 49/115) at grade I of the modified Oppenheim classification. Cultures were done in 26.1% (n = 30/115), of which 83.9% (n = 26/30) were positive. Staphylococcus aureus was the most common organism. Duration between external fixator placement and date of injury, smoking, pin location and associated vascular injury used in one model explained 36.2% (Nagelkerke R2) of the variance in pin-tract infection and correctly classified 70.2% of cases.
Conclusion: The pin-tract infection rate was relatively high. Its reduction has to begin in the operating theatre with adherence to complete aseptic techniques, careful placement of external fixators and use of prophylactic antibiotics.
Management of Burns in Gaza-Strip: A Multicentre Clinical Audit
NA Jamie1, HY Aldaya1, HA Shammala1, S Al-Bashiti1, H Shaheen1, A Alazar1
M Ghunim1, A Al Moghrabi2 and B Bottcher1
1Islamic University of Gaza, Palestine
2Plastic Surgeon, Gaza, Palestine
Abstract
Aim: Our aim was to evaluate the management of burns in the emergency room (ER) andesenting with burns injuries to the ER for one month, and retrospectively, management of patients was evaluated, who were admitted to the ICU for one year.
Results: In the ER, 57.1% (n attitudes were mainly positive. With the reported desire to know more, this study suggests that young men are capable of being positive advocates for menstruation.
Paediatric Osteosarcoma in Sub-Saharan Africa: A Review
S Scott and R Khundkar
= 84/147) of patients were male, with a mean age of 15.4 ± 14.1. From the 147 cases, 17.7% (n = 26/147) were major burns, which included > 10% total body surface area burned (TBSA). Of these, 37.6% underwent ABCDE approach and 87.8% (n = 129/147) received sterile dressings.
Out of the 17 patients admitted to ICU, 76.5% (n = 13/17) were male, with a mean age of 19.2 ± 12.8 years. All these patients received prophylactic antibiotics, 58.8% (n = 10/17) had endotracheal intubation, 5.9% (n = 1/17) underwent central venous pressure measurement (CVP), 23.5% (n = 4/17) had ABG tested and 88.2% (n = 15/17) kidney function tests (KFT), and 64.7% (n = 11/17) received ranitidine. No patient had a chest radiograph (CXR) performed or carbon monoxide (CO) level measured.
Conclusion: This study demonstrates good adherence to guidelines in some points such as sterile dressing in 87.8% of all patients seen in ER. In other aspects of care, poor adherence to guidelines was found, such as patients presenting with major burns, who should all benefit from the ABCDE approach, though < 40% patients actually did. In contrast, antibiotics, which should only be prescribed when indicated, were given to nearly all patients admitted to the ICU.
“Menstruation, isn’t this meant for girls?” A quantitative study into young adult male understanding and attitudes towards menstruation in Malaysia
D Barnett, A Barnett, M Das and A Ng Lai Oon
University of Leeds, UK
Abstract
Aim: Our aim was to investigate the level of understanding and attitudes towards menstruation in male students in Malaysia using a questionnaire-based survey.
Methods: The study population of young adult males was sampled using convenience sampling of who passed by two high traffic locations on Sunway University Campus, Kuala Lumpur over two weeks in May 2019. Microsoft Excel and IBM SPSS Statistics were used to analyse data.
Results: Four main themes of results were identified: demographics; knowledge of menstruation; attitudes towards menstruation; and source of menstruation knowledge. Knowledge of menstruation was generally well answered but with notable exceptions for the ages of menarche and menopause. Home-setting, the studying of a healthcare-related degree, the prior receipt of menstruation information, and whether a participant thought menstruation was embarrassing or not were significant predictors of symptom score. The majority of participants did not have negative attitudes towards menstruation. Formal education was the most common source of menstruation information and the most preferred source. Over half the participants wished for more menstruation information.
Conclusion: Despite not having a complete knowledge of menstruation
University of Oxford, UK
Abstract
Aim: • To identify whether the rate of paediatric osteosarcoma (OS) in Sub-Saharan Africa (SSA) is similar to that of the UK.
• Where studies into paediatric OS are taking place.
• Identify common themes across studies to gain insight into the state of OS treatment and research in SSA.
intensive care units (ICU) of the Gaza-Strip.
Methods: A prospective study evaluated the management of patients pr
Methods: A literature review from publications through Embase and Medline.
Result: • Reported relative rate of paediatric OS as a proportion of all paediatric malignancies were found to be greater than that reported in the UK.
• Studies came from only seven countries, despite 20 in SSA being on the IACR registry.
• Themes identified were: late presentation, treatment discontinuation and an inability to follow up patients.
Conclusion: Osteosarcoma disproportionately affects children in sub-Saharan Africa as a cause of morbidity and mortality and a lack of specific data means the burden is likely to be under-estimated. Patients present with late advanced disease and frequently abandon treatment owing to the combination of advanced disease and the poor availability of chemotherapy agents leading to poor prognosis combined with an inability to afford the cost of care. The problem is ultimately one of data. Through an improvement in the digitalisation of health services, as well as community care, the paucity of data in the field may be addressed.
Perceptions and experiences of Chhaupadi and menstruation related restrictions in rural Surkhet, mid-western Nepal
N Douglas
University of Leeds, UK
Abstract
Aim: To explore women’s experiences and beliefs of Chhaupadi (a system of societal exclusion during menstruation), and its perceived impact on women’s lives and menstrual hygiene management (MHM) in rural Surkhet, Nepal.
Methods: Participants were recruited by purposive sampling through a gatekeeper identified by the project host. 20 semi-structured interviews were conducted at participants’ homes in Babiyachaur, Surkhet in May 2019. Data were triangulated through observations. Informal discussions with community leaders and an interview with the district’s deputy mayor were carried out. Data was transcribed and thematically analysed. Ethical approval was granted by the University of Leeds.
Results: The majority of women practiced Chhaupadi although most of them did not believe in it, and wanted to eradicate it. Participants described Chau houses as uncomfortable and dangerous places, which was triangulated through observations. Participants believed Chhaupadi impacts on all aspects of women’s lives, including MHM, however felt unable to stop practicing, often because of family pressures. People’s faith, beliefs, elders and religious leaders were the most commonly reported barriers to eradicating Chhaupadi.
Conclusion: Chhaupadi poses a major risk for women and girls and although many desire to eradicate the practice, they feel unable owing to gender and power inequalities. There is a need for increased empowerment of women and awareness of the risks of Chhaupadi, targeting specifically elders and religious leaders, to reduce menstruation related restrictions and ensure women’s safety.
Pre-operative HIV testing in a high prevalence country improves rates of HIV diagnosis and initiation of effective antiretroviral therapy when working in collaboration with local HIV services
A Bleakley
Royal Alexandra Hospital, Paisley, UK and Mercy Ships Hospital Physician 2017–18
Abstract
Aim: The aim of this study was to determine the benefit of pre-operative HIV testing of patients undergoing elective surgery by an NGO (Mercy Ships) in the high-prevalence sub-Saharan African country of Cameroon. The indicators of benefit included: rate of new HIV diagnoses; number of people initiated on anti-retrovirals (ARVs) as a result of pre-operative testing; change in CD4 count in patients established on ARVs for 3 months.
Methods: From August 2017 to May 2018, surgical charity Mercy Ships, based in Cameroon provided free surgical care aboard the hospital ship The Africa Mercy. All patients attended pre-operative HIV counselling and testing. A retrospective study of results was performed to determine rate of new diagnoses, number of these patients commenced on ARVs after referral to local HIV clinics and overall effect on CD4 count.
Results: HIV status was checked in 1258 patients. 63 patients tested positive for HIV giving a 5% prevalence, similar to the 5.5% estimated by the Demographic Health Survey 2004. 26 of the HIV-positive patients (41%) did not previously know their status. The average CD4 count of newly-diagnosed patients was 573 (CI 440-706). Eight of these returned after three months of antiretroviral treatment and the average CD4 count was 655 (CI 551-759).
Conclusion: Globally almost 1 million people die of HIV each year. Testing before elective surgery in sub-Saharan Africa is feasible and, when done in collaboration with supportive local HIV services, leads to increased rates of diagnosis, initiation of effective antiretroviral therapy and a safer environment for patient and healthcare providers.
Preparing HIC students for Ethical Issues faced during medical student placements in LMICs
Z Markovic-Obiago, G Brown and R Khundkar
University of Oxford, UK
Abstract
Aim: Over 40% of HIC medical students undertaking international health elective placements do so in LMICs. Both students and host institutions face numerous ethical issues surrounding these placements. We aimed to: (i) outline these ethical challenges, (ii) assess the need for training to face such challenges, (iii) produce a course able to prepare students.
Methods: As a collaboration between Oxford University Medical Students, Oxford University Bioethics Research Centre, and Oxford University Global Surgery Group we utilised a mixed methodology approach. We performed a literature search to identify key ethical issues and resources used to prepare students for them. We assessed if Oxford University Medical School’s current pre-elective preparations addressed issues from the literature. To further delineate if current provisions are sufficient, we conducted an online survey of students who have taken abroad placements.
Results: Thirteen key issues were identified in the literature. We found many elective ethics issues were not covered by current pre-elective preparation. The majority of survey responses had experienced or heard of elective ethical dilemmas (91%) and felt that an elective ethics course would be useful (83%).
Conclusion: A three-part course involving a compulsory elective ethics workshop, a pre-elective ethics online module, a post-elective ethics reflective piece and a debriefing option will be implemented by Oxford University Medical School in the 2019/2020 academic year. We are currently further assessing both student and host need by gathering more data from UK students and conducting an online survey of host institution medical students to refine the course before implementation.
Sacrococcygeal teratomas in children in sub-Saharan Africa
L Parker, R Khundkar and K Lakhoo
University of Oxford, UK
Abstract
Aim: Sacrococcygeal teratomas (SCTs) are the most common congenital tumour type but have a good prognosis with prompt and complete surgical excision. This study aimed to analyse recent literature on the presentation and management of SCTs in children in sub-Saharan Africa.
Methods: The literature search identified seven relevant cohort or case studies (within the last 20 years) and thematic analysis was performed.
Results: Firstly, the analysis highlighted high intrauterine and perinatal mortality due to SCTs in sub-Saharan Africa. This may be explained in part by limited access to antenatal technology, which improves outcomes by allowing for foetal intervention or planned Caesarean sections. Secondly, limited healthcare access was associated with delays in the presentation of patients with SCTs and, consequently, with tumour complications. Post-operative outcomes were also analysed, but long-term follow-up data in this area was lacking.
Conclusion: Improved access to appropriate antenatal technology and healthcare facilities are needed to address preventable mortality and morbidity due to SCTs in children in sub-Saharan Africa.
Surgical skills for patient safety in county hospitals: Needs assessment in Kenya
D Ojuka, OW Gachuno, RM Embogoya, K Karumba, D Wamalwa and R Nduati
Health-Professional Education Partnership Initiative, University of Nairobi, Kenya
Abstract
Aims: There is global realization of lack of access to surgical services in developing countries. World Health assembly resolution 68.15 is to help bridge this gap. A strong emphasis of quality of services should be put as we do so. The aim of this study was needs and skills gap assessment for surgical services among practicing professionals in County referral hospitals in two regions of Kenya.
Methods: Theatre users from county hospitals in two regions of Kenya were invited to a half-day group discussion on the challenges facing the surgical operations in the county hospitals. These were then constructed as either technical or non-technical skills gaps. The group agreed on a model survey for all of them to fill to complete the needs assessments.
Results: A total of 54 theatre users participated in this consultation 28 in Nairobi and 26 in Western Kenya and they included general surgeons, orthopaedic surgeon, ENT specialist, obstetrician gynaecologist, anaesthetist and theatre nurses. Nine hospitals of the eleven responded to the online survey. The key challenges were inadequate staffing, inadequate theatre space and equipment and complications as a result of non-supervision of the medical officers by the consultants. These were constructed as leadership and advocacy, ethical conducts among other technical and non-technical skills gaps.
Conclusion: There are technical and non-technical skills gaps which may affect patient safety in the county hospitals that can be improved through targeted skills-based courses.
The current state of gastrointestinal endoscopy services in Uganda
M Doe
Specialty Registrar in General Surgery, South West Deanery, UK
Abstract
Aim: Gastrointestinal (GI) conditions requiring formal endoscopic diagnosis and management are common in Uganda. This study explores the current availability and price of endoscopy in Uganda to provide an overall picture of services.
Methods: All hospitals offering endoscopy in Uganda were contacted and a representative endoscopist identified. Representatives were interviewed using a 13-point questionnaire focusing on staffing, availability and pricing.
Results: 13 hospitals (3 government, 5 mission, 5 private) offer diagnostic GI endoscopy, 5 provide therapeutic services, the majority in Kampala. 23 upper GI endoscopists are active in Uganda. Approximately 350 upper GI and 60 lower GI procedures are performed across Uganda each month. Centre workload range was 2–150 procedures monthly.
Outside the private sector, almost all centres rely on donated equipment and all charge with an average fee of $29 upper GI and $37 lower GI. Four representatives described active issues with equipment that compromised their service.
Conclusion: Since the first endoscopy in Uganda 30 years ago, access to affordable diagnostic and therapeutic services have improved but remain limited and difficult to access. Future efforts to improve services should focus on full utilisation of existing departments, limiting cost and training more practitioners. A national endoscopy society will provide a formal vehicle and attract international support.
The Use of Mosquito Nets in Hernia Repair
A Kamath, R Khundkar, D Sharma and K Lakhoo
University of Oxford, UK
Abstract
Aim: Hernia repair is one of the most common surgical procedures undertaken globally, but the exorbitant cost of commercial mesh (over $100) used in these operations often renders this prohibitively expensive in low- and middle-income countries (LMICs). Untreated hernias are extremely debilitating, limiting capacity to work. Mosquito nets can cost under $0.01 in LMICs, and for many years, there has been a question as to whether these may be used in place of commercial mesh in hernioplasty.
Methods: A literature review was performed on research papers in which the primary outcomes were hernia complications/recurrence, with raw data included. Further searches were performed comparing properties such as wound healing, tensile strength, and sterilisation techniques between mosquito nets and commercial mesh.
Results: Mosquito nets are comparable to commercially available polypropylene mesh (such as Ultrapro®), with complications in 17.8% (vs. 26.5%) and recurrence in 0.3% (vs. 0%) cases. These nets also have a greater tensile strength than commercial mesh (43.0 vs. 35.5 N/cm), and promote excellent wound healing when examined histologically. The major obstacle to the use of these nets in hernioplasty is the process of sterilisation – existing techniques can be expensive or damage the nets’ structure, but there is not yet enough evidence supporting an alternative maintaining both sterility and the nets’ structural integrity.
Conclusion: Mosquito nets are a suitable alternative to commercial mesh with regard to a number of properties, and with a little refinement in sterilisation techniques, they may become a mainstay in hernioplasty – both in LMICs and elsewhere.
Upper Gastrointestinal Endoscopy in Uganda: A Literature Review
M Doe
Specialty Registrar in General Surgery, South West Deanery, UK
Abstract
Aim: Upper gastrointestinal (UGI) endoscopy is an important investigation that is essential for formal diagnosis of GI conditions in Uganda. Availability is limited meaning conditions such as peptic ulceration are treated empirically without formal diagnosis.
This study reviews all published literature on UGI endoscopy in Uganda, examining the findings and quality of research based in the country.
Methods: A literature search of electronic databases PUBMED, MEDLINE and EMBASE was conducted. All articles describing adult UGI endoscopy in Uganda were reviewed. Paediatric investigations were excluded.
Results: 15 papers published 1987 to 2016 from 8 different journals were reviewed. A total of 8043 diagnostic endoscopies were performed, 88% of which were examined retrospectively and 9% identified oesophageal malignancy. The main focus (4 papers) was dyspepsia and H.Pylori prevalence. One study was conducted rurally (Pakwach), the rest were made in large cities.
Conclusions: Despite being available in Uganda since the 1980s, there remains a paucity of prospective data on UGI endoscopy activity in Uganda. Almost all studies are from single centres serving urban populations. Oesophageal malignancy is prevalent. As endoscopy availability increases in Uganda, future studies should aim to collaboratively collect larger prospective datasets and include rural populations. A national endoscopy society and registry could facilitate this.
Upscaling Anaesthesia through Technology in Low Resource Settings: Lessons from Lifebox
Y Shammoon and R Khundkar
University of Oxford, UK
Abstract
Aim: With 70% of medical equipment in low- and middle-income countries lying unused in the “equipment graveyard”, this challenges the numerous novel technologies being proposed to ameliorate global anaesthesia provision. To better inform the design strategies of future low-resource anaesthetic innovations, we analyse the performance of one of the most successful low-resource technologies, the Lifebox pulse oximeter.
Methods: We conducted a literature review on the challenges facing global anaesthesia, focusing on the Lifebox oximeter as a case study.
Results: From the perspective of device demand the Lifebox oximeter is impressive, with over 18000 oximeters being delivered since its 2011 inception, comfortably avoiding the “equipment graveyard”. Several reasons underlie Lifebox’s success, including their commitment to training and comprehensive research into power-sourcing, durability, cost and repairs –influencing oximeter design –ensuring target area compatibility. In terms of evaluation, the oximeter’s performance is less clear. To date there are no published studies collating global data on how the oximeter affected clinical outcomes – as well as its interplay with existing infrastructure and labour- nor detailed studies on long-term device location tracking and maintenance. This lack of data hampers meaningful technological refinement and assessment of device contributions towards reducing long-term patient morbidity.
Conclusions: Analysis of the Lifebox oximeter has highlighted context-specific design and robust long-term evaluation strategies, from the point of inception, as crucial to the success and longevity of novel technological interventions. Ultimately however, no single innovation will be sufficient to solve the global anaesthesia problem; this requires continuous development across infrastructure, labour and cross-specialty collaboration.
What is the provision of plastic surgery within the COSECSA countries?
A Chopra and R Khundkar
University of Oxford, UK
Abstract
Aim: Reconstruction is key to the treatment of malignancy, trauma and congenital disease which make up a larger proportion of the surgical burden of disease. Therefore adequate training in plastic surgery is crucial to target the substantial burden of disease. This study compared the provision of plastic surgery and demand for plastic surgery, as indicated by the rate of road traffic accidents (RTAs), within the countries that make up the College of Southern, Eastern and Central Africa (COSECSA), and the United kingdom and the United States.
Method: A search of the COSECSA database for registered Fellows of Plastic Surgery was performed. The World Health Organisation Road Traffic Accident Database was used to obtain data for road traffic deaths and thereby estimate RTA rates. This process was then repeated for the respective databases for the United Kingdom and the United States.
Results: The United States and United Kingdom had a significantly greater provision of plastic surgery, despite a significantly lower burden of injury from RTAs than in COSECSA countries. Several COSECSA countries had no registered plastic surgeons. Countries with established ‘in country’ training programmes had greater number of plastic surgeons.
Conclusion: Whilst we recognise the significant limitations of this study, it suggests a deficit in plastic surgery provision in COSECSA countries compared with the United Kingdom and the United States. It is crucial to provide adequate plastic surgery training in COSECSA countries to improve RTA outcomes.
