Impact of gender bias on women surgeons: a South African perspective.

A recent article in this journal by Katrina Hutchison exposes and addresses the cumulative effects of implicit bias on women in surgery. We doubt that there is a single woman in any surgical field who has not experienced both implicit and explicit bias. Many of the issues facing women in surgery seem to be mirrored in both the developed and developing countries. There is little literature describing the exact situation in Africa. South African government institutions have made a concerted effort to improve the representation of minorities in business, education and the health sector. In the hospital setting, hiring is done by means of a quota system based on demographics within that particular sector. This has also resulted in a number of unforeseen epistemic biases. This policy-driven 'forced' hiring of female candidates also led to feelings of doubt in the candidates themselves about their merits and competence and capabilities. This epistemic bias can then filter down, feeding the already prevalent imposter syndrome and confidence issues felt by many female surgical trainees. Not only do we need to aim to change the culture in surgical departments by changing the image of the 'stereotypical surgeon', we need to extend this message out into our training institutions, communities and peoples' homes. We believe that this is the only way to change a culture steeped in implicit bias, to be more inclusive of women and other minority groups and shed the assumption that they are lesser.

Osteomyelitis complicating secondarily infected atopic eczema: two case reports and a narrative literature review.

BACKGROUND: Atopic eczema is a relapsing, itchy chronic cutaneous inflammatory disease that commonly affects children. The disease is often complicated by cutaneous infections such as eczema herpeticum, eczema vaccinatum and a varied number of bacterial infections - impetigo, cellulitis and erysipelas. However, rare case reports of infective endocarditis, otitis media and osteo-articular infections have been associated with atopic eczema. These associations possibly represent the extracutaneous infectious complications of atopic eczema. CASE PRESENTATION: Here we present two cases of osteomyelitis in HIV negative children with habitual scratching of poorly managed and/or uncontrolled atopic eczema respectively. Both cases presented to the orthopaedic surgeons and were admitted as acute phalangeal osteomyelitis and acute - on - chronic tibial osteomyelitis respectively. The first case was an 8 year old girl who had moderate-severe poorly-controlled atopic eczema and contiguously spread phalangeal osteomyelitis. The second case was an 11 year old pre-pubertal boy who had untreated atopic eczema and tibial osteomyelitis possibly from haematogenously spread Staphylococcus aureus infection. Both were successfully discharged from hospital and currently have well controlled eczema. The 11 year old patient is also being reviewed monthly by the orthopaedic surgeons and is chronic suppressive antibiotics. He may require sequestrectomy, should it be needed. CONCLUSIONS: Invasive staphylococcal and streptococcal osteo-articular (OA) infection can arise as an extra-cutaneous infectious complication of poorly controlled atopic eczema. It is more common in the 3 to 15 year age group and especially in boys with a septic arthritis to osteomyelitis ratio of around 29:5. Clinicians should maintain a high index of suspicion in patients with moderate-severe atopic eczema and they ought to promptly manage these OA infections with intravenous antibiotics to avoid further complications.