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BACKGROUND፡ The thyroid, along with the breast, lung, and bone marrow, is among the most radiosensitive organs. This study aims to assess the rate of unnecessary radiation exposure to the thyroid gland in patients who had chest Computed Tomography (CT) at a large teaching hospital. METHOD: Hospital-based retrospective cross-sectional study on 1,306 patients who underwent chest CT from July 2018 to January 2019. Thyroid gland inclusion along with the CT dose of the studies was evaluated. Data was collected by evaluating chest CT scans from Picture Archive and Communication System (MedWeb). RESULT: Out of 1306 patients, who had Chest CT scans intravenous iodinated contrast media was used in 95.4% of the CT scans. The thyroid was included in 99.8% of the scans, out of which 76.9% included the whole thyroid gland. Among the patients who had previous CT scans, 75.3% had one previous scan and 24.7% had two previous scans. DLP (Dose Length Product) in mGycm was lower in females (360.33±32) compared to males (426.45±378.4). The lowest DLP value was observed in the pediatric patients in the age range of 1-5 years which was 146.83, while the highest was observed among those above 18 years of age with mean DLP of 418.31. CONCLUSION: The majority of chest CT scans unnecessarily include the whole thyroid gland, which is one of the most sensitive organs for radiation-induced effects. Authors recommend optimized technique for chest scans to avoid future impacts.

BACKGROUND: Typhlitis, (neutropenic enterocolitis), is a necrotizing enteropathy of the right colon, and is characterized by the clinical triad of fever, abdominal pain, neutropenia and imaging findings of right-side colonic inflammation. It is seen in the setting of severe neutropenia in immune suppressed patients who undergo treatment for malignancies, in those who have organ transplant(s) or congenital or other acquired immunosuppression. We report the clinical and imaging findings of typhlitis in pediatric cancer patients who had received chemotherapy in the largest tertiary center in Addis Ababa, Ethiopia over a period of 20 months. METHODS: The medical records of hospitalized cancer patients on treatment and with suspected typhlitis and with ultrasound reports were screened (November 2018- July 2020). Retrospective analysis of the clinical and sonographic data of those with typhlitis was done. RESULTS: Typhlitis was identified in 4.2% (12/286) of the patients on chemotherapy. 11 (91.7%) had hematologic malignancies (leukemia, lymphoma), one had a solid tumor (Head and neck embryonal RMS). Most (83.3%) had abdominal pain, diarrhea and neutropenia. Fever was identified in 67.7%. All had ultrasound evidence of typhlitis. and treated with IV antibiotics. Neither complications requiring surgical intervention nor death were seen. CONCLUSION: The magnitude of disease was comparable to what had previously been reported in other studies. While the presence of clinical a triad should prompt suspicion for the diagnosis, sonography can be used for confirmation and follow up obviating radiation, with good access in a resource limited setting.

Purpose: COVID-19 led to significant reduction in surgery worldwide. Studies, however, of the effect on surgical volume for pediatric patients in low- and middle-income countries (LMICs) are limited.Methods: A survey was developed to estimate waitlists in LMICs for priority surgical conditions in children. The survey was piloted and revised before it was deployed over email to 19 surgeons. Pediatric surgeons at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey from February 2021 to June 2021. The survey included the total number of children awaiting surgery and estimates for specific conditions. Respondents were also able to add additional procedures. Results: Public hospitals had longer wait times than private facilities. The median waitlist was 90 patients and the median wait time was 2 months for elective surgeries.Conclusion: Lengthy surgical wait times affect surgical access in LMICs. COVID-19 had been associated with surgical delays around the world, exacerbating existing surgical backlogs. Our results revealed significant delays for elective, urgent and emergent cases across Sub-Saharan Africa. Stakeholders should consider approaches to scale the limited surgical and perioperative resources in LMICs, create mitigation strategies for future pandemics, and establish ways to monitor waitlists on an ongoing basis.

Background Cross-Cultural adaptation of a cognitive screening instrument requires careful planning and its implementation is complex, expensive and time consuming. This study aims to cross culturally adapt AD8 using the WHO translation and adaptation process guidelines in preparation for the development of a mobile health based dementia screening app at the primary care center of Ethiopia. Methods The panel discussed forward and backward translated AD8 instrument items alongside with the original English version of AD8 and Lawshe’s CVR critical value to adapt them to the interim final and the reconciled Amharic versions of AD8 respectively. The reconciled Amharic version was pilot tested, a cognitive interview was conducted, and the results were analyzed and a summary report was generated to adapt it to the final Amharic version of AD8. Results The Lawshe’s CVR value was less than the expected CVR critical value (0.75) for all of the forward translated items of AD8 except for the ‘Question items # 3 &7’. The panel substituted words and/or phrases in the title, instructions and ‘Question items # 1 & 6’; and added ‘Radio’ to the Question item # 4. The Lawshe’s CVR value (1.0) was greater than the expected CVR critical value (0.75) for all of the backward translated instrument items of AD8. The internal reliability of the reconciled Amharic version of AD8 was very good with a Cronbach’s alpha value of 0.875. Cognitive interview study participants verbalized lived experiences to reason and explain the way the reconciled Amharic version of AD8 question items was understood. The reconciled Amharic version was adapted without any modification as the final Amharic version of AD8. Conclusion changes made, reasons for change, and a vote of consensus for each question item of AD8 was documented at every step of deliberations of the panel. The Amharic version of AD8 demonstrated a very good internal reliability with strong item correlation. The Amharic version of AD8 fulfills the perquisite for the development of mobile health based AD8 dementia screening at primary care settings of Ethiopia and aligns with the WHO task-shifting strategy of dementia screening.

Background As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. Methods 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. Results From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. Conclusions This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

BACKGROUND፡ Surgical Site Infection (SSI) and wound dehiscence are two early complications of laparotomy causing significant morbidity and mortality. This study was conducted to determine the prevalence and risk factors of SSI and wound dehiscence in pediatric surgical patients.METHODS: We performed a prospective observational study of all pediatric surgical patients who underwent laparotomy at Tikur Anbessa Specialized Hospital, Ethiopia, from December 2017 to May 2018. Data collected included demographics, operative indication, nutritional status, prophylactic antibiotics administration, and duration of operation. Primary outcome was SSI; secondary outcomes were hospital stay and other postoperative complications, including wound dehiscence and mortality. Data were analyzed using SPSS, Version 23. Fisher’s exact and Chi-squared tests used to report outcomes. Multivariable logistic regression was used to identify variables associated with SSI, wound dehiscence and other outcomes.RESULTS: Of 114 patients, median age was 46 months [range: 1day-13years]; 77(67.5 %) were males. Overall SSI rate was 21.05%. Nine (7.9%) developed wound dehiscence while 3(2.6%) had abdominal contents evisceration. Overall mortality rate was 2.6%. In multivariate analysis, prophylactic antibiotics administration (AOR=13.05, (p=0.006)), duration of procedure (AOR=8.62, (p=0.012)) and wound class (AOR=16.63, (p=0.034)) were independent risk factors for SSI while SSI was an independent predictor of prolonged hospital stay, >1 week (AOR=4.7, p=.003,) and of wound dehiscence (AOR=33. 96,p=0.003). Age (p=0.004) and malnutrition (p1 hour before surgery and operative time >2 hours are independent predictors of SSI.

Background The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines. Methods Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines. Results A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56–1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities. Conclusions Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.

BACKGROUND Nonsyndromic orofacial clefts (NSOFCs) represent the most common congenital anomalies in the head and neck region. Multiple factors contribute to the occurrence of this anomaly. The etiology of NSOFCs in the Ethiopian population has not been investigated prior to this study. AIMS OF THE STUDY To assess the role of maternal environmental factors in the occurrence of NSOFCs in the Ethiopian Population. METHODS The authors used unmatched case control study design and evaluated the role of environmental factors to the occurrence of NSOFCs in the Ethiopian population. The participants were recruited from the same institution (Yekatit 12 Hospital Medical College). The authors studied 760 mothers (359 mothers of children born with NSOFCs and 401 mothers of children born without any congenital anomalies). Univariate and multivariate logistic regression analyses were used to calculate relative risk by odds ratio and 95% confidence interval. RESULTS Mothers who gave history of bronchial asthma and mothers who were admitted for threatened abortion had a higher risk of delivering a child with NSOFCS P value=0.013; AOR=0.194, 95% CI [0.053-0.712], P value

Workye Tigabie,1 Woubedel Kiflu,2 Fisseha Temesgen,2 Hanna Getachew,2 Tihitena Nigussie,2 Belachew Dejenie,2 Amezene Tadesse,2 Miliard Derbew2 1Department of Surgery, St. Peter Specialized Hospital, Addis Ababa, Ethiopia; 2Department of Surgery, Pediatrics Surgery Unit, Tikur Anbessa Hospital, Addis Ababa, EthiopiaCorrespondence: Workye Tigabie, Email workye62@gmail.comBackground: Inguinal hernia is one of the most frequent reasons for referral to the pediatric surgery unit. The incidence ranges from 1% to 5% in the pediatric population. Surgery for inguinal hernia is among the most commonly performed procedures, with good overall outcomes and few complications.Objective: The study aimed to evaluate the pattern and outcome of inguinal hernia surgery in children.Methodology: This retrospective 5-year cross-sectional study was conducted on all pediatric patients with inguinal hernia (age < 13 years) operated on between September 1, 2014, and August 31, 2019, in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.Results: The male to female ratio of inguinal hernia was 19:1. It was slightly more predominant on the right side and bilaterality occurred in about 10.6% of cases. The mean age at presentation was 15 months, and the average waiting time for patients to be operated on was 5 months. The overall incarceration and strangulation rates were 24% and 3.8%, respectively. Infants had a higher risk of incarceration/strangulation than other children. Among patients who underwent elective surgery, 63% (53/84) of operations were carried out as day-case surgery. The overall mortality, complication rate, and recurrence risk following surgery were 0.9%, 11.5%, and 9.6%, respectively. Bilaterality increased the occurrence of late postoperative complications.Conclusion: All inguinal hernia cases were indirect hernias operated on by standard open surgical techniques. Our study showed increased incarceration rates, recurrences, and complications after surgery. This is because of the delayed presentation of patients and delayed intervention for patients. Therefore, early and timely intervention with proper surgical techniques should always be considered.Keywords: inguinal hernia, incarceration, outcome, pattern, day-case surgery

To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed for an average period of 14.72 ± 3.67 months (range 9-21months) after surgery.One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%)14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complication rate in proximal than distal hypospadias. Distal hypospadias were the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome.

Background A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings. Methods We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes. Results All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention. Conclusion We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

This quality improvement study evaluates the sustainability of Clean Cut, a surgical infection prevention program implemented at hospitals in Ethiopia.

Typhlitis, (neutropenic enterocolitis), is a necrotizing enteropathy of the right colon, and is characterized by the clinical triad of fever, abdominal pain, neutropenia and imaging findings of right-side colonic inflammation. It is seen in the setting of severe neutropenia in immune suppressed patients who undergo treatment for malignancies, in those who have organ transplant(s) or congenital or other acquired immunosuppression. We report the clinical and imaging findings of typhlitis in pediatric cancer patients who had received chemotherapy in the largest tertiary center in Addis Ababa, Ethiopia over a period of 20 months.The medical records of hospitalized cancer patients on treatment and with suspected typhlitis and with ultrasound reports were screened (November 2018- July 2020). Retrospective analysis of the clinical and sonographic data of those with typhlitis was done.Typhlitis was identified in 4.2% (12/286) of the patients on chemotherapy. 11 (91.7%) had hematologic malignancies (leukemia, lymphoma), one had a solid tumor (Head and neck embryonal RMS). Most (83.3%) had abdominal pain, diarrhea and neutropenia. Fever was identified in 67.7%. All had ultrasound evidence of typhlitis. and treated with IV antibiotics. Neither complications requiring surgical intervention nor death were seen.The magnitude of disease was comparable to what had previously been reported in other studies. While the presence of clinical a triad should prompt suspicion for the diagnosis, sonography can be used for confirmation and follow up obviating radiation, with good access in a resource limited setting.

Pediatric age groups constitute more than 50% of the Sub-Saharan African, SSA, population. Very poor socioeconomic conditions and rare and advanced pathologies are the major health challenges of the region. Despite the overwhelming burden of diseases in the region, the health workforce and infrastructure are underdeveloped. The overall poverty, poor hygiene and sanitation, and widespread infectious disease with very limited infrastructures (road, health institutions) on top of lack of government commitment to improve the health of their people are some of the drawbacks that fail to address the unmet needs of pediatric health in SSA. Complications of surgical care have become a major cause of morbidity and mortality with significant implications for public health. These issues are magnified in developing countries, especially sub-Saharan Africa. The challenge is even more prominent in pediatric surgery, where the population is larger, and there is a shortage of specialists. In this lecture, I describe the difficulties faced from the East African and Ethiopian perspective as well as the role of colleges from high income countries to support SSA to address the unmet pediatric surgery needs.

BACKGROUND፡ Ethiopia has a high unmet need for pediatric surgical conditions. Over the past 5 years, new changes have been introduced to the pediatric surgery division at Addis Ababa University to overcome this issue. The changes include initiation of pediatric surgery residency, allocating operating room for pediatric surgery, weekend surgical campaign and starting ultrasound guided hydrostatic reduction. We conducted this study to evaluate the pattern and outcome of pediatric surgical cases after these changes.METHODS: The study was a retrospective review conducted at Tikur Anbessa Hospital from Jan – Dec 2019. Data was collected from duty report forms that included emergency procedures, admissions and mortalities. Data on elective procedures was collected from operation theater log books.RESULTS: Overall, a total of 1590 pediatric surgical procedures were performed during 2019 of which 942 cases were elective and 648 were emergency. This was an increment in number of surgeries performed by 75%. The leading emergency procedure was aerodigestive foreign body removal which increased by 46%. Surgery for intussusception has decreased by 30% with increasing use of hydrostatic reduction. Overall, average morbidity and mortality was 3.5% and 6.9% respectively. Morbidity and mortality rates were similar throughout the year.CONCLUSION: The study shows increased productivity over the past year with the changes made in the department. There is also no increment in morbidity and mortality during the start of the academic year. This implies adequate consultant supervision of residents during transition.

There has been a significant increase in the number of students, residents, and fellows from high-income settings participating in short-term global health experiences (STGHEs) during their medical training. This analysis explores a series of ethical conflicts reported by medical residents and fellows from Emory University School of Medicine in the United States who participated in a 1-month global health rotation in Ethiopia. A constant comparative analysis was conducted using 30 consecutive reflective essays to identify emerging categories and themes of ethical conflicts experienced by the trainees. Ethical conflicts were internal; based in the presence of the visiting trainee and their personal interactions; or external, occurring due to witnessed events. Themes within internal conflicts include issues around professional identity and insufficient preparation for the rotation. External experiences were further stratified by the trainee’s perception that Ethiopian colleagues agreed that the scenario represented an ethical conflict (congruent) or disagreed with the visiting trainee’s perspective (incongruent). Examples of congruent themes included recognizing opportunities for collaboration and witnessing ethical conflicts that are similar to those experienced in the United States. Incongruent themes included utilization of existing resources, issues surrounding informed consent, and differing expectations of clinical outcomes. By acknowledging the frequency and roots of ethical conflicts experienced during STGHEs, sponsors may better prepare visiting trainees and reframe these conflicts as collaborative educational experiences that benefit both the visiting trainee and host providers.

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p

IntroductionAs childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).MethodsA multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A pResults1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.ConclusionMortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

Heteropagus (parasitic) twin is a type of conjoined twinning in which a partially formed defective twin is attached to an otherwise normal twin. It is an extremely rare anomaly. In this paper, we describe five cases we encountered over the past 9 years. Except one, all presented early within a few days of birth. None of them shared an organ but two had bony/visceral connections. All surgeries were successful, and we only encountered wound complications. To the best of our knowledge this is the largest compilation of original cases in a parasitic twin report. Keywords: Conjoined twin, Parasitic twin, Heteropagus twin, Ethiopia

We sought to identify independent, nonacademic predictors of medical and nursing student intent to migrate abroad or from rural to urban areas after graduation in low- and middle-income countries (LMIC). This was a cross-sectional survey of 3,199 first- and final-year medical and nursing students at 16 training institutions in eight LMIC. Questionnaires assessed demographics, career intentions, and preferences regarding selected career, location, and work-related attributes. Using principal component analysis, student preferences were reduced into four discrete categories of priorities: 1) work environment resources, 2) location livability, 3) altruistic job values, and 4) individualistic job values. Students' preferences were scored in each category. Using students' characteristics and priority scores, multivariable proportional odds models were used to derive independent predictors of intentions to emigrate for work outside the country, or to work in a rural area in their native country. Students prioritizing individualistic values more often planned international careers (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.16-1.78), whereas those prioritizing altruistic values preferred rural careers (aOR = 1.82, 95% CI = 1.50-2.21). Trainees prioritizing high-resource environments preferentially planned careers abroad (aOR = 1.38, 95% CI = 1.12-1.69) and were unlikely to seek rural work (aOR = 0.60, 95% CI = 0.49-0.73). Independent of their priorities, students with prolonged prior rural residence were unlikely to plan emigration (aOR = 0.67, 95% CI = 0.50-0.90) and were more likely to plan a rural career (aOR = 1.53, 95% CI = 1.16-2.03). We conclude that use of nonacademic attributes in medical and nursing admissions processes would likely increase retention in high-need rural areas and reduce emigration "brain drain" in LMIC.

BACKGROUND: Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias.MATERIALS AND METHODS: This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study.RESULTS: A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p

With the lowest measured rate of surgery in the world, Ethiopia is faced with a number of challenges in providing surgical care. The aim of this study was to elucidate challenges in providing safe surgical care in Ethiopia, and solutions providers have created to overcome them. Semi-structured interviews were conducted with 10 practicing surgeons in Ethiopia. Following de-identification and immersion into field notes, topical coding was completed with an existing coding manual. Codes were adapted and expanded as necessary, and the primary data analyst confirmed reproducibility with a secondary analyst. Qualitative analysis revealed topics in access to care, in-hospital care delivery, and health policy. Patient financial constraints were identified as a challenge to accessing care. Surgeons were overwhelmed by patient volume and frustrated by lack of material resources and equipment. Numerous surgeons commented on the inadequacy of training and felt that medical education is not a government priority. They reported an insufficient number of anaesthesiologists, nurses, and support staff. Perceived inadequate financial compensation and high workload led to low morale among surgeons. Our study describes specific challenges surgeons encounter in Ethiopia and demonstrates the need for prioritisation of surgical care in the Ethiopian health agenda.LCoGS: The Lancet Commission on Global Surgery; LMIC: low- and middle-income country.

Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature.A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature.Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared.While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

Background: Undescended testis is one of the commonest congenital malformations seen in boys. The aim of this study is to evaluate the pattern of presentation, approach to diagnosis, treatment and follow up in Tikur Anbesa Specialized Hospital, a tertiary teaching hospital in Ethiopia. Methods: This is a retrospective cross sectional study of all boys with undescended testis operated in Tikur Anbesa Specialized Hospital between September 2012 and August 2014. Results: Of 82 boys operated within the study period, 66 boys with 78 undescended testes are studied. Twenty-six percent (17/66)came before the age of 2 years, while the majority of the study group, 50% (33/66), presented beyond 5 years of age. Of the 17 boys brought to the hospital before 2 years, only 41% (7/17) them were treated before the age of two years. The majority 89% (59/66) of the boys were treated after 2 years of age. Seventy-one testes of 78 [91%] were in the inguinal canal, 5 were intra-abdominal and 2 were absent. 46% (36/78) were on the left side, 29% (23/78) on the right side and the rest were bilateral. Among the 54 boys who had ultrasound examination, the ultrasound report is consistent with operative findings in 33 [61%]. Associated congenital malformations were found in 31.8% (21/66) of the boys. Hypospadia was the predominant malformation comprising 38% (8/21) of the total congenital malformations. Orchidopexy was done for 82% (64/78) of the total testes, orchiectomy was done for 9% (7/78) and biopsy was taken in 1 case. Among the total operated boys only 62% (41/66) were followed in our clinic; of those who had follow up 10% (4/41) testes atrophied and 1 [2%] testis retracted. Conclusion: Boys with undescended testes present and are treated late in Tikur Anbesa Hospital. As opposed to the literatures most of the undescended testes were found on the left side. Ultrasound examination cannot be the only mode of examination for undescended testes as it misses more than one third of the cases. Hypospadia is the commonest associated congenital malformation. Post operative follow up is very poor after treatment for undescended testes https://dx.doi.org/10.4314/ecajs.v22i1.10 This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source (including a link to the formal publication), provide a link to the Creative Commons license, and indicate if changes were made.

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Background Until recently, there were only a few medical schools in Ethiopia. However, currently, in response to the apparent shortage in physician workforce, the country has made huge progress with respect to the expansion of medical schools, by adopting the so-called flooding strategy. Nevertheless, the effectiveness of the intended strategy also relies on physician accessibility and turnover. Therefore, the aim of this study was to examine the distribution of physicians in the medical schools of Ethiopia and to quantify the magnitude and identify factors associated with physician turnover. Methods This organizational faculty physician workforce survey was conducted in seven government-owned medical schools in Ethiopia. Longitudinal medical workforce data set of about 6 years (between September 2009 and June 2015) were retrospectively collected from each of the medical schools. The observation time begins with the date of employment (time zero) and ends at the date on which the physician leaves the appointment/or the data collection date. Kaplan-Meier survival method was used to describe the duration of stay of physicians in the academic health care settings. A Cox proportional hazards (CPH) model was fitted to identify the risk factors for physician turnover. Results In this study, a total of 1258 faculty physicians were observed in seven medical schools which resulted in 6670.5 physician-years. Of the total, there were 198 (15.7%) turnover events and the remaining 1060 (84.3%) were censored. The average turnover rate is about 29.7 per 1000 physician-years of observations. Multivariate modeling revealed no statistical significant difference in the rate of turnover between males and females (adjusted hazard ratio (AHR), 1.12; 95%CI, 0.71, 1.80). However, a lower rate of physician turnover was observed among those who were born before 1975 (AHR, 0.37; 95%CI, 0.20, 0.69) compared with those who were born after 1985. Physicians with the academic rank of associate professor and above had a lower (AHR, 0.25; 95%CI, 0.11, 0.60) rate of turnover in comparison to lecturers. In addition, physicians working in Jimma University had 1.66 times higher rate of turnover compared with those working in Addis Ababa University. However, the model showed a significantly lower rate of turnover in Mekelle (AHR, 0.16; 95%CI, 0.06, 0.41) and University of Gondar (AHR, 0.46; 95%CI, 0.25, 0.84) compared with that of Addis Ababa. Physician turnover in the remaining medical schools (Bahir Dar, Haromaya, and Hawassa) did not show a statistically significant difference with Addis Ababa University (P > 0.05). Conclusions This study revealed a strong association between physician turnover with age, academic rank, and workplace. Therefore, the findings of the study have important implications in that attention needs to be given for the needs of faculty physicians and for improving the work environment in order to achieve a high level of retention.

Questionnaires. (DOCX 40Â kb)

To assess medical and nursing students' intentions to migrate abroad or practice in rural areas.We surveyed 3199 first- and final-year medical and nursing students at 16 premier government institutions in Bangladesh, Ethiopia, India, Kenya, Malawi, Nepal, the United Republic of Tanzania and Zambia. The survey contained questions to identify factors that could predict students' intentions to migrate. Primary outcomes were the likelihoods of migrating to work abroad or working in rural areas in the country of training within five years post-training. We assessed predictors of migration intentions using multivariable proportional odds models.Among respondents, 28% (870/3156) expected to migrate abroad, while only 18% (575/3158) anticipated a rural career. More nursing than medical students desired professions abroad (odds ratio, OR: 1.76; 95% confidence interval, CI: 1.25-2.48). Career desires before matriculation correlated with current intentions for international (OR: 4.49; 95% CI: 3.21-6.29) and rural (OR: 4.84; 95% CI: 3.52-6.66) careers. Time spent in rural areas before matriculation predicted the preference for a rural career (20 versus 0 years: OR: 1.53, 95% CI: 1.19-1.98) and against work abroad (20 versus 0 years: OR: 0.69, 95% CI: 0.50-0.96).A significant proportion of students surveyed still intend to work abroad or in cities after training. These intentions could be identified even before matriculation. Admissions standards that account for years spent in rural areas could promote greater graduate retention in the country of training and in rural areas.Évaluer les intentions des étudiants en médecine et en soins infirmiers concernant une émigration à l'étranger ou une pratique dans les zones rurales.Nous avons interrogé 3199 étudiants en première année et en dernière année de médecine ou de soins infirmiers dans les 16 plus grandes institutions gouvernementales au Bangladesh, en Ethiopie, en Inde, au Kenya, au Malawi, au Népal, en Tanzanie et en Zambie. L'enquête contenait des questions pour identifier les facteurs qui pourraient prédire les intentions d'émigration des étudiants. Les résultats primaires étaient les probabilités d'émigration en vue de travailler à l'étranger ou dans les zones rurales du pays où a été livrée la formation, dans les cinq ans suivant la fin de la formation. Nous avons évalué les indicateurs des intentions d'émigration en utilisant des modèles à cotes proportionnelles multivariés.Parmi les répondants, 28% (870/3156) espèrent émigrer à l'étranger, alors que seuls 18% (575/3158) envisagent une carrière en zone rurale. Les étudiants infirmiers désirant pratiquer à l'étranger (rapport des cotes, RC: 1,76; intervalle de confiance à 95%, IC 95%: 1,25–2,48) étaient plus nombreux que les étudiants en médecine. Les souhaits de carrière avant toute installation officielle étaient corrélés avec les intentions actuelles pour les carrières à l'international (RC: 4,49; IC 95%: 3,21–6,29) et dans les zones rurales (RC: 4,84; IC 95%: 3,52–6,66). Le temps passé dans les zones rurales avant installation prédit une préférence pour une carrière rurale (20 contre 0 année: RC: 1,53; IC 95%: 1,19–1,98) et contre le fait de travailler à l'étranger (20 contre 0 année: RC: 0,69; IC 95%: 0,50-0,96).Une part importante des étudiants interrogés continue à vouloir travailler à l'étranger ou dans les villes après la fin de leur formation. Ces intentions pouvaient être identifiées même avant leur installation. Des normes d'admission tenant compte des années passées dans les zones rurales pourraient favoriser une meilleure rétention des diplômés dans le pays de leur formation et dans les zones rurales.Evaluar las intenciones de los estudiantes de medicina y enfermería de emigrar al extranjero o trabajar en zonas rurales.Se encuestó a 3199 estudiantes de medicina y enfermería de primer y último curso de 16 instituciones gubernamentales de primer nivel en Bangladesh, Etiopía, India, Kenya, Malawi, Nepal, Tanzania y Zambia. La encuesta incluyó preguntas para identificar los factores que podrían predecir las intenciones de emigrar de los estudiantes. Los resultados primarios fueron las probabilidades de emigrar para trabajar en el extranjero o en zonas rurales en el país de formación en los cinco años posteriores a esta. Los indicadores de las intenciones de migración se evaluaron por medio de modelos de probabilidades proporcionales multivariables.Entre los encuestados, el 28 % (870/3156) esperaba emigrar al extranjero, mientras que solo el 18 % (575/3158) preveía una carrera rural. Más estudiantes de enfermería que de medicina deseaban desarrollar su profesión en extranjero (proporción de probabilidad, OR: 1,76; intervalo de confianza del 95 %, IC: 1,25–2,48). Los deseos sobre la carrera profesional antes de la matriculación se correspondían con los deseos actuales de desarrollar una carrera internacional (OR: 4,49; 95 % IC: 3,21–6,29) y rural (OR: 4,84; 95 % IC: 3,52–6,66). El tiempo pasado en zonas rurales antes de la matriculación predijo la preferencia por una carrera rural (20 frente a 0 años: OR: 1,53; 95 % IC: 1,19–1,98) y en contra de trabajar en el extranjero (20 frente a 0 años: OR: 0,69; 95 % IC: 0,50–0,96).Una proporción significativa de los estudiantes encuestados todavía tiene la intención de trabajar en el extranjero o en ciudades una vez finalizados los estudios. Dichas intenciones pudieron identificarse incluso antes de la matriculación. Las normas de admisión que contabilizan los años pasados en zonas rurales podrían promover una mayor retención de los graduados en el país de formación y en las zonas rurales.تقييم نوايا طلاب الطب والتمريض للهجرة إلى الخارج أو العمل في المناطق الريفية.أجرينا دراسة استقصائية عن 3199 طالب من طلاب الطب والتمريض في السنة الأولى والأخيرة في 16 مؤسسة حكومية رائدة في بنغلاديش وإثيوبيا والهند وكينيا وملاوي ونيبال وجمهورية تنزانيا المتحدة وزامبيا. وتضمنت الدراسة الاستقصائية أسئلة لتحديد العوامل التي يمكنها أن تنبئ بنوايا الطلاب للهجرة. وتمثلت الحصائل الأولية في احتمالات الهجرة بغية العمل في الخارج أو العمل في المناطق الريفية في بلد التدريب في غضون خمس سنوات بعد قضاء التدريب. وقمنا بتقييم عوامل التكهن بنوايا الهجرة باستخدام نماذج الاحتمال النسبية متعددة المتغيرات.توقعت نسبة 28 % (870/3156) من المستجيبين الهجرة إلى الخارج، في حين لم يتوقع العمل في المناطق الريفية سوى 18 % فقط (575/3158). ومقارنة بطلاب الطب، رغب المزيد من طلاب التمريض في العمل خارج بلادهم (نسبة الاحتمال: 1.76؛ فاصل الثقة 95 %، فاصل الثقة: 1.25–2.48). وارتبطت رغبات العمل قبل الالتحاق بالتدريب بالنوايا الراهنة في الحصول على وظائف دولية (نسبة الاحتمال: 4.49؛ فاصل الثقة 95 %: من 3.21 إلى 6.29) وريفية (نسبة الاحتمال: 4.84؛ فاصل الثقة 95 %: من 3.52 إلى 6.66). وتنبأ الوقت الذي تم قضاؤه في المناطق الريفية قبل الالتحاق بالتدريب بتفضيل العمل في المناطق الريفية (20 مقابل 0 سنة: نسبة الاحتمال: 1.53، فاصل الثقة: 95 %، فاصل الثقة: من 1.19 إلى 1.98) وعدم العمل في الخارج (20 مقابل 0 سنة: نسبة الاحتمال: 0.69، فاصل الثقة: 95 %، فاصل الثقة: من 0.50 إلى 0.96).ما زالت نسبة كبيرة من الطلاب الذين تم دراستهم استقصائياً ينوون العمل في الخارج أو في المدن بعد قضاء التدريب. ويمكن تحديد هذه النوايا حتى قبل الالتحاق بالتدريب. ويمكن أن تعزز معايير القبول التي تفسر عدد السنوات التي تم قضاؤها في الريف قدراً أكبر من استبقاء الخريجين في بلد التدريب وفي المناطق الريفية. .评估医疗和护理学生出国或在农村地区就业的意向。我们调查了孟加拉国、埃塞俄比亚、印度、肯尼亚、马拉维、尼泊尔、坦桑尼亚联合共和国和赞比亚16所主要政府院校3199名一年级和毕业班的医疗和护理学生。调查所包含的一些问题被用来确定能够预测学生迁移意向的因素。主要结果是在五年在岗培训期间迁移到国外工作或在培训国农村地区工作的可能性。我们使用多变量比例优势模型评估迁移意向预测因素。在应答者中，28%（870/3156）期望出国，仅18%（575/3158）期望在乡村工作。较之医疗学生，更多护理学生期望到国外从业（优势比，OR：1.76；95%置信区间，CI：1.25-2.48）。大学入学之前的职业期望与当前国际（OR：4.49；95% CI：3.21-6.29）和乡村（OR：4.84；95% CI：3.52-6.66）就业意向有关联。入学之前在农村地区呆过的时间预示了想到农村就业（20比对0年：OR：1.53，95% CI：1.19-1.98）以及不希望出国工作（20比对0年：OR：0.69，95% CI：0.50-0.96）的程度。很大一部分受调查的学生仍打算在培训后出国工作或在城市工作。甚至在入学之前就可以分辨出这种意向。在招生标准中列入农村地区呆过的时间，可以将更多的毕业生留在其接受培训的国家和农村地区。Оценить стремление студентов, обучающихся на врачей и медсестер, переехать за границу или продолжить практику в сельской местности.Мы опросили 3199 студентов первого и последнего курсов, обучающихся на врачей и медсестер в 16 лучших государственных образовательных учреждениях Бангладеш, Эфиопии, Индии, Кении, Малави, Непала, Объединенной Республики Танзании и Замбии. Исследование включало вопросы, помогающие определить факторы, влияющие на желание студентов переехать. Основные результаты определили вероятность переезда за границу или в сельскую местность в стране обучения для работы в течение пятилетнего периода после завершения обучения. Мы оценили факторы, влияющие на стремление переехать, с помощью многоаспектной пропорциональной модели.Среди опрашиваемых лиц 28% (870/3156) планируют переезд за границу и лишь 18% (575/3158) планируют продолжить карьеру в сельской местности. Будущие медсестры чаще, чем будущие врачи, хотят получить работу за границей (коэффициент вероятности: 1,76, 95%; доверительный интервал: 1,25–2,48). Планируемая дальнейшая карьера до поступления в высшее учебное заведение совпадала с текущими стремлениями: для желающих работать за границей (коэффициент вероятности: 4,49, 95%; доверительный интервал: 3,21–6,29) и для желающих работать в сельской местности (коэффициент вероятности: 4,84, 95%; доверительный интервал: 3,52–6,66). Проживание в сельских районах до поступления в высшее учебное заведение часто предопределяло желание работать в сельской местности (20 лет по отношению к 0 лет: коэффициент вероятности: 1,53, 95%; доверительный интервал: 1,19–1,98) по сравнению с желанием работать за границей (20 лет по отношению к 0 лет: коэффициент вероятности: 0,69, 95% доверительный интервал: 0,50–0,96).Значительная часть опрошенных студентов после обучения планируют работать за границей или в городе. Данные цели иногда были определены еще до поступления в высшее учебное заведение. Введение льгот при приеме в учебные заведения может способствовать удержанию выпускников в стране обучения и сельских регионах.