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‘What About The Mother?’ Women׳S And Caregivers׳ Perspectives On Caesarean Birth In A Low-Resource Setting With Rising Caesarean Section Rates, Helena Litorp, Andrew Mgaya, Hussein Kidanto, Sara Johnsdotter, Birgitta Essén

Faculty of Health Sciences, East Africa

Objective in light of the rising caesarean section rates in many developing countries, we sought to explore women׳s and caregivers׳ experiences, perceptions, attitudes, and beliefs in relation to caesarean section.

Design qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.

Setting a public university hospital in Dar es Salaam, Tanzania.

Participants we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone …

‘What About The Mother?’ Women׳S And Caregivers׳ Perspectives On Caesarean Birth In A Low-Resource Setting With Rising Caesarean Section Rates, Helena Litorp, Andrew Mgaya, Hussein Kidanto, Sara Johnsdotter, Birgitta Essén

Obstetrics and Gynaecology, East Africa

Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women׳s and caregivers׳ experiences, perceptions, attitudes, and beliefs in relation to caesarean section.

Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.

Setting: a public university hospital in Dar es Salaam, Tanzania.

Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone …

Venous Thromboembolism-Incidence Of Deep Venous Thrombosis And Pulmonary Embolism In Patients With Head And Neck Cancer: A Tertiary Care Experience In Pakistan, Naeem Sultan Ali, Ahmad Nawaz, Montasir Junaid, Maliha Kazi, Shabbir Akhtar

Department of Surgery Docs

Abstract

Introduction Although venous thromboembolism (VTE) is seen with morbidity and mortality in various surgical specialties, scarce data are available in the head and neck surgery domain. Objective We aim to determine the incidence of VTE in patients receiving surgery for head and neck cancer. Methods Four hundred thirteen patients who underwent head and neck surgery procedures between 2005 and 2013 were reviewed retrospectively. All patients with head and neck surgery had received thromboprophylaxis (i.e., compression stockings and subcutaneous heparin). Patient demographics, operating time, and length of hospital stay were analyzed. The incidence of symptomatic deep venous thrombosis (DVT) and …

Knowledge And Attitude Towards Rape And Child Sexual Abuse – A Community-Based Cross-Sectional Study In Rural Tanzania, Muzdalifat Abeid, Projestine Muganyizi, Siriel Massawe, Rose Mpembeni, Elisabeth Darj, Pia Axemo

Obstetrics and Gynaecology, East Africa

Background, Violence against women and children is globally recognized as a social and human rights concern. In Tanzania, sexual violence towards women and children is a public health problem. The aim of this study was to determine community knowledge of and attitudes towards rape and child sexual abuse, and assess associations between knowledge and attitudes and socio-demographic characteristics.

Methods, A cross-sectional study was undertaken between May and June 2012. The study was conducted in the Kilombero and Ulanga rural districts in the Morogoro Region of Tanzania. Men and women aged 18–49 years were eligible for the study. Through a three-stage …

Treatment Of Sigmoid Volvulus By Deflation Versus Surgery: A Single Site Report, Yonas Raru, Patricia Messmer, Arthur Williams, Dawood Sultan, Ashenafi Adale, Yalelet Shiferaw, Paul Hart, Hugh Pettigrew

Internal Medicine

Background: Although very common in developing regions like Africa, sigmoid volvulus (SV) has a much lower incidence in the West. There is a dearth of literature on the treatment of SV in countries with limited resources. This paper reports study results using a cohort of 200 SV patients in a low-income developing country. Objectives: The aim of this study was to identify the characteristics associated with length of hospital stay (LOS) in the largest sample of sigmoid volvulus patients drawn from a single site within a single year and to examine the effects of treatment complications and previous attacks of …

Proceedings Of The African Pathologists Summit; March 22-23, 2013; Dakar, Senegal: A Summary, Shahin Sayed

Pathology, East Africa

Context: This report presents the proceedings of the African Pathologists Summit, held under the auspices of the African Organization for Research and Training in Cancer.

Objectives: To deliberate on the challenges and constraints of the practice of pathology in Sub-Saharan Africa and the avenues for addressing them.

Participants: Collaborating organizations included the American Society for Clinical Pathology; Association of Pathologists of Nigeria; British Division of the International Academy of Pathology; College of Pathologists of East, Central and Southern Africa; East African Division of the International Academy of Pathology; Friends of Africa-United States and Canadian Academy of Pathology Initiative; International Academy …

Psychobiobehavioral Model For Preterm Birth In Pregnant Women In Low- And Middle-Income Countries, Shahirose S. Premji, Ilona S. Yim, Aliyah Dosani (Mawji), Zeenatkhanu Kanji, Salima Sulaiman, Wangira Musana, Pauline Samia, Kiran Shaikh, Nicole Letourneau

School of Nursing & Midwifery, East Africa

Preterm birth (PTB) is a final common outcome resulting from many interrelated etiological pathways; of particular interest is antenatal psychosocial distress (i.e., stress, anxiety, and depression). In LMI countries, both exposure to severe life stressors and rate of PTB are on average greater when compared with high-income countries. In LMI countries women are exposed to some of the most extreme psychosocial stress worldwide (e.g., absolute poverty, limited social resources). High prevalence of antenatal stress and depression have been observed in some studies from LMI countries. We propose a psychosocial, biological, and behavioral model for investigating the complex multisystem interactions in …

A Report From The First Regional Pain Medicine Symposia In East, Central And Southern African Region. (Ecsa-R)-“The Rhino Model In Pain Education In Africa”, Thikra Sharif, John Bugo

Anaesthesiology, East Africa

The 1st Regional pain medicine symposia were held between the 14th and 18th of November 2011 in 3 cities (Nairobi, Mombasa and Dar-es-salaam), across 2 countries, Kenya and Tanzania. It was funded by the International Association for the Study of Pain (IASP), through the IASP developing country education grant for 2011 and The Aga Khan University Hospital Nairobi (AKUHN). It was organized by faculty from the Pain Management Unit (PMU) AKUHN. The Pain medicine educators were from PMU, AKUHN and from Specialists in Pain International Network (SPIN).

The aims of the symposia were to introduce the Rhino model concept, the …

Perceptions Of The Preparedness Of Medical Graduates For Internship Responsibilities In District Hospitals In Kenya: A Qualitative Study, Patricia Muthaura, Tashmin Khamis, Mushtaq Ahmed, Syeda Ra’Ana Hussain

Obstetrics and Gynaecology, East Africa

Background: Aga Khan University is developing its undergraduate medical education curriculum for East Africa. In Kenya, a 1 year internship is mandatory for medical graduates’ registration as practitioners. The majority of approved internship training sites are at district hospitals. The purposes of this study were to determine: (1) whether recent Kenyan medical graduates are prepared for their roles as interns in district hospitals upon graduation from medical school; (2) what working and training conditions and social support interns are likely to face in district hospital; and (3) what aspects of the undergraduate curriculum need to be addressed to overcome perceived …

Intimate Partner Violence After Disclosure Of Hiv Test Results Among Pregnant Women In Harare, Zimbabwe, Simukai Shamu, Christina Zarowsky, Tamara Shefer, Marleen Temmerman, Naeemah Abrahams

Obstetrics and Gynaecology, East Africa

Background: HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women.

Methods: In this cross sectional study we interviewed 1951 postnatal women who tested positive and negative for HIV about IPV experiences following HIV test disclosure, using an adapted WHO questionnaire. Multivariate regression models assessed factors associated with IPV after disclosure and controlled for factors such as previous IPV and other known behavioural factors associated with IPV.

Results: Over …

Maternal Near-Miss And Death And Their Association With Caesarean Section Complications: A Cross-Sectional Study At A University Hospital And A Regional Hospital In Tanzania, Helena Litorp, Hussein Kidanto, Mattias Rööst, Muzdalifat Abeid, Lennarth Nyström, Birgitta Essén

Faculty of Health Sciences, East Africa

Background The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

Methods We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital …

Gendered Violence, Hiv Acquisition, And Clinical/Behavioral Research, Liz Barr, Michele Peake Andrasik, Claire Rappoport, Jessica Mooney, Annet Davis Vogel, Lisa Rossi, Amina Alio

Journal of Health Disparities Research and Practice

HIV incidence and prevalence rates for US women continue to increase, especially among Black and Latina women. In addition, the link between violence and HIV acquisition has been well documented. However, the interaction between violence, HIV risk, and HIV acquisition remains an under-addressed issue in current clinical and behavioral HIV research designs. Because violence against women plays an important role in HIV acquisition and transmission, it is imperative for clinical research to address violence in trial design and implementation. In this article, we discuss the prevalence of violence in women’s lives; the role violence plays in HIV acquisition; and the …

Perceived Barriers Among Pregnant Women Towards Cervical Cancer Screening, Visavilwa Vincent Lamuka

Master of Medicine in Family Medicine

Background: Cervical cancer remains the most common cancer in women in Eastern Africa in general and Tanzania in particular. However, to a large extent cervical cancer is preventable by effective screening programmes as has been demonstrated in many developed countries. Developing countries lack formal national screening programmes. Screening is usually mainly done opportunistically. Objective: To assess the perceived barriers to uptake of cervical cancer screening among pregnant women attending antenatal clinics in two hospitals in Dar es Salaam. Methodology: This was a qualitative study, conducted at two hospitals in Dar es salaam, a government facility (Amana District Hospital) and a …

An Assessment Of Whether Medical Doctors Have The Knowledge That Would Enable Them To Competently Deliver Tobacco Cessation Services, Miriam Miima Khamonya

Master of Medicine in Family Medicine

Background: Tobacco use is the leading cause of preventable morbidity and mortality globally. The international community recognizes this epidemic and compelling evidence exists on the significant contribution of the health care provider in propagating the success of tobacco cessation. The World Health Organization highlights minimal implementation of tobacco control policies by Tanzania despite a rise in tobacco use prevalence. Medical doctors’ competence is a reflection on our commitment to tobacco cessation service delivery. Main Objectives: To assess whether medical doctors have the knowledge that would enable them to competently deliver tobacco cessation services. Specific Objectives 1. To assess medical doctors’ …

Pediatric Cerebral Palsy In Africa: Where Are We?, Kirsten A. Donald, Angelina M. Kakooza, Robinson D. Wammanda, Macpherson Mallewa, Pauline Samia, Haydar Babakir, David Bearden, Annette Majnemer, Darcy Fehlings, Michael Shevell, Harry Chugani, Jo M. Wilmshurst

Paediatrics and Child Health, East Africa

Cerebral palsy is the most common cause of physical disability in children worldwide. However, little is reported on this condition in the African context. Doctors from 22 countries in Africa, and representatives from a further 5 countries outside Africa, met to discuss the challenges in the evaluation and management of children with cerebral palsy in Africa and to propose service needs and further research. Basic care is limited by the poor availability of diagnostic facilities or medical personnel with experience and expertise in managing cerebral palsy, exacerbated by lack of available interventions such as medications, surgical procedures, or even regular …

Understanding The Barriers To Contraceptive Use In Hiv-Positive Women Of Child Bearing Age In Dar-Es-Salaam, Tanzania, Tabitha-Alexandria Njeri Nyanja

Master of Family Medicine

Title: Understanding the barriers to contraceptive use among HIV-positive women of child bearing age in Dar-es-Salaam, Tanzania- a multi-site study Purpose: The purpose of this study was to explore the perceived barriers to contraceptive use and identify the factors that influence contraceptive choice, as well as the relationship of these among HIV-positive women living in an urban population in Dar-es-Salaam Tanzania. Goals and Objectives: To determine the perceived barriers to contraceptive use among HIV-positive women of child-bearing age attending the Care Treatment Centres (CTCs) Tanzania and in the President’s Emergency Plan for AIDS Relief (PEPFAR) supported CTCs within Dar-es-salaam. Methodology: …

Epidemiology Of Malaria In A Village In The Rufiji River Delta, Tanzania: Declining Transmission Over 25 Years Revealed By Different Parasitological Metrics, Anna Färnert, Victor Yman, Manijeh Vafa Homann, Grace Wandell, Leah Mhoja, Marita Johansson, Salome Jesaja, Johanna Sandlund, Kazuyuki Tanabe, Ulf Hammar, Matteo Bottai, Zul Premji, Anders Björkman, Ingegerd Rooth

Pathology, East Africa

Background: Assessments of the epidemiology of malaria over time are needed to understand changes in transmission and guide control and elimination strategies.

Methods: A longitudinal population study was established in 1985 in Nyamisati village in the Rufiji River Delta, Tanzania. A physician and research team lived in the village 1984–2000. Parasite prevalence by microscopy and two PCR methods, spleen rates and haemoglobin levels were measured in repeated cross-sectional surveys between 1985 and 2010. Passive surveillance of malaria cases was maintained until end 1999. Bed nets were distributed after the surveys 1993, 1999 and 2010.

Results: In 1985, overall parasite prevalence …

Pediatric Cerebral Palsy In Africa: A Systematic Review, Kirsten A. Donald, Pauline Samia, Angelina Kakooza-Mwesige, David Bearden

Paediatrics and Child Health, East Africa

Cerebral palsy is a common neurologic problem in children and is reported as occurring in approximately 2-2.5 of 1000 live births globally. As is the case with many pediatric neurologic conditions, very little has been reported on this condition in the African context. Resource-limited settings such as those found across the continent are likely to result in a different spectrum of etiologies, prevalence, severity as well as management approaches. This review aims to establish what has been reported on this condition from the African continent so as to better define key clinical and research questions.

Rwandan Young People’S Perceptions On Sexuality And Relationships: Results From A Qualitative Study Using The ‘Mailbox Technique’, Kristien Michielsen, Pieter Remes, John Rugabo, Ronan Van Rossem, Marleen Temmerman

Obstetrics and Gynaecology, East Africa

This study aimed to gain more insight into young Rwandans’ perceptions on sex and relationships, which is essential for formulating effective sexual and reproductive health (SRH) promotion interventions. Using a ‘mailbox technique’, this paper studies the spontaneous thoughts of Rwandan young people on sexuality. Mailboxes were installed in five secondary schools in the Bugesera district and students were invited to write about their ideas, secrets, wishes, desires and fears on sexuality and relationships. Of the 186 letters collected, 154 addressed SRH topics. The letters were analysed in NVivo 9 using a theoretical model on vulnerability. Two stereotypical sexual interactions co-exist: …

Aetiology Of Acute Febrile Episodes In Children Attending Korogwe District Hospital In North-Eastern Tanzania, C. Mahende, B. Ngasala, J. Lusingu, A. Butichi, P. Lushino, M. Lemnge, Zul Premji

Pathology, East Africa

Introduction: Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed. This situation underscores the need to explore the possible causes of febrile episodes in patients presenting with symptoms at the Korogwe District Hospital (KDH).

Methods: A hospital based cross-sectional study was conducted at KDH, north-eastern Tanzania. Patients aged 2 to 59 months presenting at the outpatient department with an acute medical condition and fever (measured axillary temperature ≥37.5°C) were enrolled. Blood samples were examined for malaria parasites, human immunodeficiency virus (HIV) and bacterial infections. A urine culture was …

Using Verbal Autopsy To Measure Causes Of Death: The Comparative Performance Of Existing Methods, C.J.L. Mahende, R. Lozano, A.D. Flaxman, P. Serina, D. Phillips, A. Stewart, S.L. James, A. Vahdatpour, C. Atkinson, M.K. Freeman, S.L. Ohno, R. Black, S.M. Ali, A.H. Baqui, L. Dandona, E. Dantzer, G.L. Darmstadt, V. Das, U. Dhingra, A. Dutta, W. Fawzi, S. Gomez, B. Hernandez, R. Joshi, H.D. Kalter, A. Kumar, V. Kumar, M. Lucero, S. Mehta, Zul Premji, D. Ramirez-Villalobos, H. Remolador, I. Riley, M. Romero, M. Said, D. Sanvictores, S. Sazawal, V. Tallo, A. D. Lopez

Pathology, East Africa

Background: Monitoring progress with disease and injury reduction in many populations will require widespread use of verbal autopsy (VA). Multiple methods have been developed for assigning cause of death from a VA but their application is restricted by uncertainty about their reliability.

Methods: We investigated the validity of five automated VA methods for assigning cause of death: InterVA-4, Random Forest (RF), Simplified Symptom Pattern (SSP), Tariff method (Tariff), and King-Lu (KL), in addition to physician review of VA forms (PCVA), based on 12,535 cases from diverse populations for which the true cause of death had been reliably established. For adults, …

Impact Of Community-Based Interventions For The Prevention And Control Of Malaria On Intervention Coverage And Health Outcomes For The Prevention And Control Of Malaria, Rehana A. Salam, Jai K. Das, Zohra S. Lassi, Zulfiqar A. Bhutta

Department of Paediatrics and Child Health

In this paper, we aim to evaluate the effectiveness of community-based interventions (CBIs) for the prevention and management of malaria. We conducted a systematic review and identified 42 studies for inclusion. Twenty-five of the included studies evaluated the impact of the community-based distribution of insecticide-treated nets (ITNs), indoor residual spraying (IRS), or impregnated bed sheets; 14 studies evaluated intermittent preventive therapy (IPT) delivered in community settings; two studies focused on community-based education for malaria prevention; and one study evaluated environmental management through drain cleaning. Our analysis suggests that, overall, the community-based delivery of interventions to prevent and control malaria resulted …

Grand Multiparity: Is It Still A Risk In Pregnancy?, Andrew H. Mgaya, Siriel N. Massawe, Hussein Kidanto, Hans N. Mgaya

Faculty of Health Sciences, East Africa

Background The association of grand multiparity and poor pregnancy outcome has not been consistent for decades. Classifying grand multiparous women as a high-risk group without clear evidence of a consistent association with adverse outcomes can lead to socioeconomic burdens to the mother, family and health systems. We compared the maternal and perinatal complications among grand multiparous and other multiparous women in Dar es Salaam in Tanzania.

Methods A cross-sectional study was undertaken at Muhimbili National Hospital (MNH). A standard questionnaire enquired the following variables: demographic characteristics, antenatal profile and detected obstetric risk factors as well as maternal and neonatal risk …

Cholera Vaccination Campaign Contributes To Improved Knowledge Regarding Cholera And Improved Practice Relevant To Waterborne Disease In Rural Haiti, Omowunmi Aibana, Molly F Franke, Jessica E Teng, Johanne Hilaire, Max Raymond, Louise C Ivers

Faculty, Staff and Student Publications

BACKGROUND: Haiti's cholera epidemic has been devastating partly due to underlying weak infrastructure and limited clean water and sanitation. A comprehensive approach to cholera control is crucial, yet some have argued that oral cholera vaccination (OCV) might result in reduced hygiene practice among recipients. We evaluated the impact of an OCV campaign on knowledge and health practice in rural Haiti.

METHODOLOGY/PRINCIPAL FINDINGS: We administered baseline surveys on knowledge and practice relevant to cholera and waterborne disease to every 10th household during a census in rural Haiti in February 2012 (N = 811). An OCV campaign occurred from May-June 2012 after …

Increasing Caesarean Section Rates Among Low-Risk Groups: A Panel Study Classifying Deliveries According To Robson At A University Hospital In Tanzania, Helena Litorp, Hussein Kidanto, Lennarth Nystrom, Elisabeth Darj, Birgitta Essén

Faculty of Health Sciences, East Africa

Background Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country.

Methods We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age ≥ 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of …

Sickle Cell Disease In Pregnancy: Trend And Pregnancy Outcomes At A Tertiary Hospital In Tanzania, Projestine S. Muganyizi, Hussein Kidanto

Faculty of Health Sciences, East Africa

SCD in pregnancy is associated with increased adverse fetal and maternal outcomes. In Tanzania where the frequency of sickle cell trait is 13% there has been scanty data on SCD in pregnancy. With progressive improvement in childhood survival the burden of SCD in pregnancy will increase. We analyzed all deliveries at Muhimbili National Hospital (MNH) from 1999 to 2011. Fetal and maternal outcomes of SCD deliveries were compared with non-SCD. Data were analyzed using IBM SPSS statistics version 19. Chi square and Fisher Exact tests were used to compare proportions and the independent t-test for continuous data. To predict risks …

Risk Of Childhood Asthma In A Tropical African Urban Setting: A Case - Control Study At The Aga Khan Hospital, Dar-Es-Salaam, Tanzania, Lynda C. Koech

Master of Medicine in Family Medicine

Objective: To determine the modifiable and non-modifiable risk factors for childhood asthma in children aged between two and 15years in a tropical urban East-African setting. Methods: Hospital based case-control study matched for age + two months and sex. Data were obtained from parents of cases and controls using a structured interviewer-administered questionnaire. The study sample consisted of 226 cases of two to 15years old, with physician-confirmed asthma, who met a set of defined clinical criteria and 226 controls with no previous diagnosis or symptoms of asthma matched by sex and age (+two months). The Risk Factors included in this study …

Perception Of Final Year Undergraduate Medical Students Towards Family Medicine In Dar Es Salaam, Tanzania, Eric Luggar Aghan

Master of Medicine in Family Medicine

Primary health care was identified as the ideal model of health care delivery during the Alma Atta conference in USSR in 1978. The World Health Organization urged member countries to adopt it as a model of health care service delivery to their people. Since then many countries have adopted a primary health care model including Tanzania. In countries such as Cuba and Costa Rica where primary health care has successfully been implemented, access to affordable and quality health care service to all has resulted in lowered morbidity, mortality, improved quality and longevity of life. The success story behind primary health …

Usefulness Of Plasmodium Falciparum-Specific Rapid Diagnostic Tests For Assessment Of Parasite Clearance And Detection Of Recurrent Infections After Artemisinin-Based Combination Therapy, B. Aydin-Schmidt, M. Mubi, U. Morris, M. Petzold, B.E. Ngasala, Zul Premji, A. Bjorkman, A. Martensson

Pathology, East Africa

Background: Rapid diagnostic test (RDT) is an important tool for parasite-based malaria diagnosis. High specificity of RDTs to distinguish an active Plasmodium falciparum infection from residual antigens from a previous infection is crucial in endemic areas where residents are repeatedly exposed to malaria. The efficiency of two RDTs based on histidine-rich protein 2 (HRP2) and lactate dehydrogenase (LDH) antigens were studied and compared with two microscopy techniques (Giemsa and acridine orange-stained blood smears) and real-time polymerase chain reaction (PCR) for assessment of initial clearance and detection of recurrent P. falciparum infections after artemisinin-based combination therapy (ACT) in a moderately high …

Validation Of The Ottawa Ankle Rules At A Tertiary Teaching Hospital: A Cross-Sectional Study, Mark Karanja Tharao

Master of Medicine in General Surgery

Introduction: Ankle joint and foot injuries are among the commonest injuries seen at the Accident and Emergency Department of any hospital. Within the United States it is the second most common musculoskeletal injury seen by physicians. Assessment of these injuries is done clinically and when deemed necessary a radiograph is requested. Studies have shown that radiographs are ordered in over 95% of cases yet the prevalence of fractures is in the range of 15-20%. This means that more than 80% of patients are exposed to unnecessary radiation. The Ottawa ankle rules have been designed to reduce the need for performing …