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Background Endemic goiter is highly prevalent in Uganda, placing a considerable surgical burden on the healthcare system. Across Africa, prevalence varies widely, reaching 60.2%, with visible goiter affecting 30% of Uganda’s rural population despite salt iodization programs. Despite evidence supporting thyroidectomy under local anesthesia (LA) for selected cases, its importance is underestimated moreover with limited access to general anesthesia (GA) and critical care providers in resource-constrained settings. The trial compared outcomes of thyroidectomy under LA versus GA in grade 1–2 uncomplicated euthyroid goiter patients in Uganda, with an aim to assess feasibility of LA as an alternative technique. Methods In this prospective equivalence randomized, single-blind controlled trial, participants with grade 1–2 uncomplicated euthyroid goiters were enrolled and randomly assigned to two arms (LA and GA) during surgical camps in Uganda. The study compared early postoperative outcomes, including nausea, vomiting, hematoma formation, transient voice changes, and pain at 6, 12, and 24 h. It also assessed overall incurred material and medication costs, patient satisfaction using a 5-point Likert scale, and willingness to undergo a similar procedure with the same anesthetic technique at 30 days. Results Fifty-eight participants undergoing thyroidectomy received random assignment, twenty-nine for each arm. No significant differences were found between the 2 groups in demographics, symptom duration, and early post-operative complications or patients’ level of satisfaction ( P  > 0.05). However, the overall material and medication costs were significantly lower in the LA Group ( P  < 0.001). Conclusions Thyroidectomy under LA can be performed in a well-selected patient population with low complication rates and comparable patient satisfaction to GA. These findings may support LA for thyroidectomy as a valuable cost-efficient alternative, especially in low-resource settings with fewer GA providers. Trial registration First registered on 31/07/2022, PACTR202208635457430 by Pan African Clinical Trial Registry.

Introduction Perforated peptic ulcer is the worst complication of peptic ulcer disease whose burden is disproportionately higher in low-income settings. However, there is paucity of published data on the patterns of perforated peptic ulcer in the region. The aim of this study was to determine the factors associated with anatomical patterns of peptic ulcer perforation, as well as the clinical, socio-demographic, and anatomical patterns among patients in Uganda. Methods This was a cross sectional study that enrolled 81 consecutive patients with perforated peptic ulcers. Using a structured pretested questionnaire the social demographic and clinical characteristics were obtained. At surgery, the patterns of the perforations were determined. Logistic regression was done in SPSS version 22 to determine the factors associated with the anatomical patterns. Results Perforated peptic ulcer disease was more prevalent among males (79.5%), peasants (56.8%) and those from rural areas (65.4%). Majority of study participants were of blood group O (43.2%). Gastric perforations were more common (74.1%). Majority of the perforations were found anteriorly (81.5%). Being a casual laborer was independently associated with lower odds of having a gastric perforation compared to being a peasant farmer ( P  < 0.05). Conclusion Public health campaigns aimed at prevention of peptic ulcer perforations should prioritize the males, peasants and those living in rural areas. When a patient in our setting is suspected to have a peptic ulcer perforation, the anterior part of the stomach should be considered as the most likely site involved more so in peasant farmers.

Background Endemic goiter is highly prevalent in Uganda at 60.2%, contributing to the high surgical burden. While compelling evidence suggest that in selected cases, thyroidectomy under local anesthesia (LA) is associated with fewer post-operative complications, low costs, and short hospital stays, local anesthesia is not considered a priority technique for thyroidectomy in resource-constrained settings such as Uganda, despite having fewer general anesthesia (GA) and critical care providers. The objective of this trial is to compare euthyroidectomy under local versus general anesthesia among patients with grade 1–2 uncomplicated euthyroid goiter in Uganda. Methods This prospective equivalence randomized, single-blind controlled trial protocol will be conducted among eligible participants with grade 1–2 uncomplicated euthyroid goiters. The recruitment processes will start in October 2022 and end in April 2023. Consenting participants with an indication for thyroidectomy will be randomized into two arms of 29 participants in each arm during the Bulamu Health Care Organization surgical camps in Uganda. Discussion The primary outcome of this trial protocol is to compare the early post-operative complications of euthyroidectomy done under LA versus GA. The outcome variables include post-operative pain based on visual analogue scale, nausea, vomiting, hematoma formation, and transient voice changes determined at an interval of 6, 12, and 24 h and at 30 days. In addition, we shall compare the surgical site infection rates, procedure costs, hospital stay, and patients’ level of satisfaction based on a 5-point Likert scale and their willingness to undergo a similar surgery using the same anesthetic technique between the two groups. We hypothesize that euthyroidectomy under LA could potentially offer similar benefits as GA, reduce costs related to procedure, complications, and hospital stay while at the same time mitigating the unmet need for surgery attributable to shortage of general anesthesia providers and critical care facilities in low-income settings. Trial registration Pan African Clinical Trial Registry PACTR202208635457430. Registered on 11 th August 2022. All items from the WHO trial registration data set are within the protocol. Version number and date: version 3, 15/03/2023.

Background Research shows that trauma team formation could potentially improve effectiveness of injury care in rural settings. The aim of this study was to determine the feasibility of rural trauma team training amongst medical trainees and traffic law enforcement professionals in Uganda. Methods Prospective multi-centre interrupted time series analysis of an interventional training based on the 4th edition of rural trauma team development course of the American College of Surgeons. Trauma related multiple choice questions (MCQs), and trauma non-technical skills were assessed pre-and post-training between September 2019- August 2023. Acceptability of the training for promulgation to other rural regions and its relevance to participants’ work needs were evaluated on 5- and 3-point Likert scales respectively. The median MCQ scores (IQR) were compared before and after training at 95% CI, regarding p  < 0.05 as statistically significant. Triangulation with open-ended questions was obtained. Time series regression models were applied to test for autocorrelation in performance using Stata 15.0. Ethical approval was obtained from Uganda National Council for Science and Technology (Ref: SS 5082). Results A total of 500 participants including: 66 (13.2%) traffic police officers, 30 (6.0%) intern doctors, 140 (28.0%) fifth year and 264 (52.8%) third-year medical students were trained. Among the 434 medical trainees who completed the trauma-based MCQ assessment, the median pre- and post-test scores were 60%, IQR (50–65) and 80%, IQR (70–85) respectively. Overall, the mean difference between pre- and post-test scores was statistically significant (z = 16.7%, P|z|=<0.0001). Most participants strongly agreed to promulgate 389 (77.8%), relevance to their educational 405 (81.0%), and work needs 399 (79.8%). Each of the course components was rated above 76.0% as being very relevant. There was an overall increment in median (IQR) trauma-nontechnical skills team performance scores from 12 (9-14) to 17 (15-20) after the training ( p  < 0.001), with police teams advancing from 9.5 (6.0-12.5) to 19.5 (17.0-21.5) ( p  < 0.001). Conclusion This study demonstrates that rural trauma team development training had a positive effect on the test scores of course participants. The training is feasible, highly acceptable and regarded as relevant amongst medical trainees and traffic law enforcement professionals who provide first-aid to trauma patients in resource-limited settings. The findings could inform the design of future trauma teams in rural communities. Trial registration Retrospective registration (UIN: researchregistry9450). Key highlights • There is limited human and infrastructural resources for trauma care in Low-and-middle-income countries (LMICs). • Research shows that trauma education could increase the effectiveness of injury care in remote settings. • We explore the feasibility of rural trauma team development training through an educational intervention, viewing rural medical trainees and traffic law enforcement professionals as sustainable human resources for health, and discuss policy implications for LMICs.

Introduction Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25–50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended focused assessment with sonography for trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting. Methods This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53. Results eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980, P  = 0.001 versus 0.725, P  = 0.136). Combining eFAST and X-ray increased both sensitivity and accuracy. Conclusion This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

Introduction Mortality due to injuries disproportionately impact low income countries. Knowledge of who is at risk of poor outcomes is critical to guide resource allocation and prioritization of severely injured. Kampala Trauma Score (KTS), developed in 1996 and last modified in 2002 as KTS II, is still widely being used to predict injury outcomes in resource-limited settings with no further revisions in the past two decades, despite ongoing criticism of some of its parameters. The New Trauma Score (NTS), a recent development in 2017, has shown potential in mortality prediction, but a dearth of evidence exist regarding its performance in the African population. Objectives To compare NTS to the modified Kampala Trauma Score (KTS II) in the prediction of 30-day mortality, and injury severity amongst patients sustaining road traffic crashes in Ugandan low-resource settings. Methods Multi-center prospective cohort study of patients aged 15 years and above. Of the 194 participants, 85.1% were males with a mean age of 31.7 years. NTS and KTS II were determined for each participant within 30-minutes of admission and followed-up for 30 days to determine their injury outcomes. The sensitivity, specificity, and area under receiver operating characteristics curve (AUC) for predicting mortality were compared between the two trauma scores using SPSS version 22. Ethical clearance: Research and Ethics Committee of Kampala International University Western Campus (Ref No: KIU-2022-125). Results The injury severity classifications based on NTS vs. KTS II were mild (55.7% vs. 25.8%), moderate (29.9% vs. 30.4%), and severe (14.4% vs. 43.8%). The mortality rates for each injury severity category based on NTS vs. KTS II were mild (0.9% v 0%), moderate (20.7% vs. 5.1%), and severe (50% vs. 28.2%). The AUC was 0.87 for NTS (95% CI 0.808–0.931) vs. 0.86 (95% CI 0.794–0.919) for KTS II respectively. The sensitivity of NTS vs. KTS II in predicting mortality was 92.6% (95% CI: 88.9–96.3) vs. 70.4% (95% CI: 63.0-77.8) while the specificity was 70.7% (95% CI: 64.2–77.2) vs. 78.4% (95% CI: 72.1–84.7) at cut off points of 17 for NTS and 6 for KTS II respectively. Conclusions NTS was more sensitive but its specificity for purposes of 30-day mortality prediction was lower compared to KTS II. Thus, in low-resourced trauma environment where time constraints and pulse oximeters are of concern, KTS II remains superior to NTS.

Background Prolonged postoperative ileus is linked to a higher risk of additional complications, longer hospital stays, and higher healthcare expenses. There are few randomized controlled trials on the impact of chewing gum on the duration of ileus in patients undergoing emergency surgery, notably those with peritonitis. Compelling evidence from studies on elective procedures demonstrates that chewing gum can lessen the duration of ileus. This trial aimed to examine the effect of chewing gum on the length of the postoperative ileus which develop after laparotomy for gastroduodenal perforations. Materials and methods Multicentre randomized controlled trial. Fifty-two patients were randomly assigned to two treatment groups. Group A received routine care with chewing gum, while group B only received routine care. The primary outcome was the length of postoperative ileus, while the secondary outcomes were the length of hospital stay, in-hospital morbidity, and mortality. The continuous variables were compared using the nonparametric Wilcoxon Rank sum (Mann-Whitney U) test while the categorical outcomes were compared using the chi-squared test in SPSS version 26. The protocol was retrospectively registered with the WHO Pan African Clinical Trial Registry (Number: PACTR202206468032528 ) on the 1st of June 2022. Results Of the 52 participants included in the analysis, the majority were males (80.8%) with a mean age of 34.23 (SD = 11.52) years. There was no statistically significant difference in the baseline characteristics of the study participants between the two groups ( P  > 0.05 for all). The median duration of postoperative ileus was 21.5 h less in the chewing gum group (28.5 versus 50.0, P  = 0.002), while the length of hospital stay was 2.5 days less in the chewing gum group (5.4 versus 7.9, P  = 0.007). There was no significant difference noted in the occurrence of complications. Conclusion Chewing gum that is readily available and reasonably priced may help shorten the duration of post-operative ileus, which has the extra benefit of enabling early discharge.

Introduction Testicular torsion refers to ischemia of the testicle due to twisting or rotation of the vessels supplying the testes. It is a urologic emergency requiring a high index of clinical suspicion and prompt surgical intervention with management aimed at avoiding testicular loss and resulting infertility. This paper gives an update on the current situation regarding this topic in low-income settings. The aim of this study was to determine testicular salvageability and its predictors amongst patients with testicular torsion at two tertiary African hospitals. Methods This was a hospital-based multicentre longitudinal study at two tertiary hospitals in western Uganda. Patients with acute scrotum were enrolled and evaluated for testicular torsion. Those with confirmed testicular torsion underwent surgery and salvageability was reported as the primary outcome. Predictors for testicular salvageability were determined using backward binary logistic regression in SPSS version 22. Results During the study period, 232 patients with acute scrotum were enrolled. The mean age was 35.3 (SD = 20.4) years. Forty-one (17.7%) patients had testicular torsion. Only 16 (39.0%) of patients with torsion had viable testes that were salvageable. Orchiectomy was performed on 25 patients (61.0%). At multivariate analysis, a patient who presented after 48 h from the onset of symptoms was 34.833 times more likely to have orchiectomy compared to one who presented within 12 h [AOR = 34.833, (95% CI = 5.020-60.711), P < 0.001]. Conclusion In this study, the testicular salvage rate was low. The only predictor of salvageability was the time from the onset of symptoms to presentation. All males should be sensitized about the clinical features of testicular torsion to ensure early presentation to increase salvage rates.

Background Despite the benefits attributed to the use of local anesthesia (LA) for open hemorrhoidectomy (OH) in developed countries, this technique is still not considered as the first line technique in low-income countries such as Uganda; therefore, we aimed at comparing the cost of OH under LA versus Saddle block among patients with 3rd or 4th degree hemorrhoids. Methods This trial was conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. The operating time, and direct costs in (US$) including medical and non-medical were recorded. We analysed the cost in the two groups (local anesthesia versus saddle block) using SPSS version 23.0. Results Findings of fifty-eight patients were analysed including 29 participants per group. There was a significant difference in operating time and cost among the two groups (p < 0.05). The mean operating time was 15.52 ± 5.34(SD) minutes versus 33.72 ± 11.54 min for OH under LA and SB respectively. The mean cost of OH under LA was 57.42 ± 8.90 US$ compared to 63.38 ± 12.77US$ in SB group. Conclusion The use of local anesthesia for OH was found to have less operating time with high-cost effectiveness. Being affordable, local anesthesia can help to increase the turnover of patients who would otherwise wait for the availability of anesthesia provider. Policy makers should emphasize its applicability in low-income settings to help in the achievement of 2030 global surgery goals. Trial registration Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 08/10/2021.

Background There is disparity in evidence on pain assessment post open hemorrhoidectomy (OH) using local anesthesia and its use in developing countries compared to developed countries. Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3 rd or 4 th degree hemorrhoids. Methods This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3 rd or 4 th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p  < 0.05 as statically significant using visual analogue scale (VAS). Results We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486–0.773: AUC = 0.63; p  = 0.09) with a none significance by Kruskal–Wallis’s test (p:0.925). Conclusion Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3 rd or 4 th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia. Trial registration Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8 th October, 2021.