Diagnosis of Acute Appendicitis: A Cross-sectional Study on Alvarado's Score from a Low Income Country.

Background: Alvarado score is the most widely used scoring system for diagnosing acute appendicitis, globally. There have been concerns regarding the diagnostic accuracy of this score as it was shown to have lower sensitivity in certain populations like Blacks and Asians. Despite its wide clinical use in the Ethiopian set up, the diagnostic accuracy of this score remained largely unexamined in this population. Methodology: A prospective cross-sectional study was conducted and all adult patients who presented with right lower quadrant abdominal pain and evaluated with a clinical impression of acute appendicitis were enrolled in the study. Data was collected by trained surgical residents over a period of six months (August 2019- January 2020) and analysed using SPSS version 25. Results: A total of 235 patients were enrolled in this study among whom two thirds were males. The majority of the study participants (61.7%) had an Alvarado score of ≥7 while almost a quarter of them had a score of <4. The mean Alvarado score in this study was 7 ± 1.8 whereas the median and the mode were 7 and 9 respectively. The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score were 99.1%, 55.6%, 98.2% and 62.5% respectively. The sensitivity and specificity of this score was superior in males compared to females (99.3% vs 97.6% and 80% vs 25%). A score of ≥5 was found to have a sensitivity of 98.4%. Conclusion: Alvarado score was found to have good sensitivity and positive predictive value in this study. A score of ≥5 can be used to "rule in" the diagnosis of acute appendicitis. Hence, the use of Alvarado score's in the Ethiopian setup is to be encouraged.

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.

Pattern and Outcome of Acute Appendicitis: Observational Prospective Study from a Teaching Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Acute appendicitis is the most common cause of acute abdomen surgery. Despite its commonness and the abundance of literature on the subject, its diagnosis remains challenging. Delay in intervention results in complications of the process leading to increased morbidity and mortality. METHODOLOGY: An observational prospective cohort study was conducted, and all patients who had undergone appendectomy for a clinical diagnosis of appendicitis were included in the study. Data were analysed using Statistical Package for Social Sciences (SPSS) version 23. RESULTS: Half of the study participants were in the age range of 18-25 years with male preponderance (63.9%). The mean duration of symptoms was 51.3 hours. The most common presenting symptom was abdominal pain (98.2%), while right lower quadrant tenderness was the most common sign (93.4%). Abdominal ultrasound was done in 81% of the study population with a sensitivity and specificity of 95.7% and 33.3%, respectively. Three-quarters (74.4%) of the patients had uncomplicated appendicitis, while 1.8% had a grossly normal appendix. None of the appendectomy specimens were sent for pathology. The mean hospital stay was 3.2 days. The morbidity and mortality rate were 3.8% and 0.4%, respectively. CONCLUSION: Acute appendicitis was the most common emergency surgical procedure in the study period. Abdominal ultrasound was used in the majority of the patients as supplementary imaging for the diagnosis of acute appendicitis. Uncomplicated appendicitis took the major share of the intraoperative finding leading to acceptable morbidity and mortality rates.

Pattern and Outcome of Colorectal and Perianal Surgery in a Referral Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Colorectal and perianal surgery encompasses a broad range of procedures to address various pathologies arising from the colon and anorectum. Data regarding the pattern and outcome of colorectal and perianal disorders requiring surgery remains largely unknown in Ethiopia. METHODS: A descriptive cross sectional one-year review was made and all patients who were admitted and operated for colorectal and perianal disorders were included in the study. Data was collected by chart review and analyzed by SPSS version 23. RESULT: Colorectal and perianal surgeries accounted for 14.6% of the procedures in the study period. Males constituted the major share of the study population. The mean age for perianal and colorectal pathologies were 39.6±13.7 and 44.8± 16.2 years respectively. Among the colorectal disorders redundant sigmoid was the most common indication for admission 41(34.4%) followed by colorectal neoplasms 38(31.9%) while among the perianal conditions, fistula in ano was the most common pathology accounting for 69(43.4%) of admissions followed by hemorrhoids 35(22%). The overall incidence of post-operative complications in the colorectal and perianal procedure groups was found to be 29(24.4%) and 4(2.5%) respectively. There was no mortality in the perianal group whereas there were 11(9.2%) deaths in the colorectal procedure group. CONCLUSION: Colorectal surgeries accounted for a fair share of procedures among the other specialty units. The morbidity and mortality associated with colorectal procedures is fairly high and warrants attention.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. METHODS: We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). FINDINGS: We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. INTERPRETATION: Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. FUNDING: Medical Research Council of South Africa.

Family Medicine in Ethiopia: Lessons from a Global Collaboration.

BACKGROUND: Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. METHODS: The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. RESULTS: Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. CONCLUSIONS: GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps.