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Background: Sub-Saharan Africa faces the highest relative need for health care workers in the world and the emigration of physicians significantly contributes to this deficit. Few studies have explored development of these patterns during medical education. This study investigates career aspirations of medical students in two African nations with similar Human Development Indices, but distinct differences in training structure to better inform retention strategies. Methods: A cross-sectional survey was administered in 2018 to medical students in Madagascar (University of Antananarivo, University of Mahajanga) and Tanzania (Kilimanjaro Christian Medical College, KCMC). Outcomes included emigration/career intentions, and factors influencing these decisions. Analysis utilised chi-square and Fisher's exact tests (α < 0.05, two-tailed) for statistical differences, logistic regression and qualitative content analysis of free text data. Results: A total of 439 students responded to the survey with a response rate of 12.9% from Antananarivo (n = 142/1097), 11.6% from Mahajanga (n = 43/370), and 60.0% from KCMC (n = 254/423). Significantly more Malagasy (49.7%, n = 90/181) than Tanzanian (25.2%, n = 54/214) students expressed emigration intent (P < .001). Malagasy students indicating research, possibility of working abroad, or work intensity as influencing career choice more frequently expressed a desire to emigrate. Satisfaction with computer/internet access was inversely correlated with a desire to work abroad. In comparison, Tanzanian students reporting income potential as influential in their career choice or attending a private high school were more likely to express a desire to work abroad. Qualitative content analysis of free text data demonstrated deficits in faculty availability, diversity of training locations and a particular emphasis on infrastructure challenges within Madagascar. Interpretation: A significant number of students desire to work abroad. Emigration interests are influenced by access to postgraduate training, infrastructure and opportunities in academia, which differ across countries. Efforts to retain physicians

Introduction: Cardiac amyloidosis (CA) is an underdiagnosed cause of heart failure. Echocardiography provides an excellent screening tool for cardiac amyloidosis. For patients with echocardiographic findings suggestive of cardiac amyloidosis, it is unknown how frequently follow-up imaging such as 99mTc PYP-scan or cardiac MRI is obtained. Diagnosis rates after a suggestive echocardiogram as well as disparities in rates of follow-up imaging and subsequent CA diagnosis are also unknown. Methods: We extracted all index cardiac echocardiograms at our institutions of adult patients that were suggestive of a possible diagnosis of CA, which was defined as: moderate or worse left ventricular concentric hypertrophy plus grade II or grade III diastolic dysfunction or diastology could not be determined due to arrhythmia in those with atrial fibrillation. Patients with known diagnosis of amyloidosis were excluded. We determined which patients underwent further testing with 99m Tc-PYP scan or cardiac MRI. We performed a population based case control study in which we compared clinical and demographic factors between those who underwent follow-up testing with either PYP scan or cardiac MRI (cases) vs those who did not (controls). Results: Of 1348 echoes that met inclusion criteria, only 110 (8.2%) underwent PYP scan or cardiac MRI. Of those, 10.0 (11%) patients ultimately were diagnosed with CA. Between cases and controls, there was no difference in age, gender, or race/ethnicity. There were no differences in rates of HFrEF or HFpEF between cases and controls. Cases had lower rates of CKD (27% vs. 40%, p=0.01) and ESRD (8.2% vs 15%, p=0.03) and had higher rates of carpal tunnel disease (12% vs. 6%), p<0.05). The rates of cardiologist ordered echocardiograms were similar between cases and controls. In terms of echocardiogram parameters, there were higher rates of grade III diastolic dysfunction (36.7% vs 20.4%, p=0.002) and more frequent rates of severe hypertrophy (36.7% vs. 21.7% p=,0.004)) among cases vs. controls. Conclusions: Among patients with echocardiographic features suggestive of CA, follow-up testing with 99m Tc -PYP scans and Cardiac MRI, and subsequent diagnosis with CA remain low.

Background As road traffic crashes (RTCs) continue to rise in the developing world, the current growth rate and true burden of orthopaedic injuries are unknown. In 2015, we characterized the orthopaedic burden at Kilimanjaro Christian Medical Center (KCMC) in Tanzania. In this study, we re-evaluated the burden and growth-rate over three years in the absence of any system level changes. Additionally, we calculated the percentage of orthopaedic patients that received definitive fixation for their orthopaedic injury when surgery was indicated.Methods We prospectively collected data for 190 patients admitted to the orthopaedic ward at KCMC during June/July 2018. We also retrospectively reviewed available records for patients presenting to the KCMC emergency department, orthopaedic outpatient clinic and orthopaedic ward.Results Prospective data: RTC (48.6%) was the most common etiology and femur fractures (31.0%) the most common type of injury. Almost 96% of admitted patients were indicated for surgical fixation, but only 44.5% received definitive fracture treatment. Retrospective data: KCMC treated an average of 15,117 orthopaedic patients per year, representing a 35.3% growth in the orthopaedic burden compared to 2015.Conclusion The burden of orthopaedic surgical disease at KCMC continues to grow. Throughout the developing world, multiple system level constraints preclude delivery of definitive treatment for most patients. Without innovative strategies to address this situation, the discrepancy between the need for orthopaedic care and surgical care capacity in the developing world will continue to grow.

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