Leveraging artificial intelligence and data science techniques in harmonizing, sharing, accessing and analyzing SARS-COV-2/COVID-19 data in Rwanda (LAISDAR Project): study design and rationale.

BACKGROUND: Since the outbreak of COVID-19 pandemic in Rwanda, a vast amount of SARS-COV-2/COVID-19-related data have been collected including COVID-19 testing and hospital routine care data. Unfortunately, those data are fragmented in silos with different data structures or formats and cannot be used to improve understanding of the disease, monitor its progress, and generate evidence to guide prevention measures. The objective of this project is to leverage the artificial intelligence (AI) and data science techniques in harmonizing datasets to support Rwandan government needs in monitoring and predicting the COVID-19 burden, including the hospital admissions and overall infection rates. METHODS: The project will gather the existing data including hospital electronic health records (EHRs), the COVID-19 testing data and will link with longitudinal data from community surveys. The open-source tools from Observational Health Data Sciences and Informatics (OHDSI) will be used to harmonize hospital EHRs through the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). The project will also leverage other OHDSI tools for data analytics and network integration, as well as R Studio and Python. The network will include up to 15 health facilities in Rwanda, whose EHR data will be harmonized to OMOP CDM. EXPECTED RESULTS: This study will yield a technical infrastructure where the 15 participating hospitals and health centres will have EHR data in OMOP CDM format on a local Mac Mini ("data node"), together with a set of OHDSI open-source tools. A central server, or portal, will contain a data catalogue of participating sites, as well as the OHDSI tools that are used to define and manage distributed studies. The central server will also integrate the information from the national Covid-19 registry, as well as the results of the community surveys. The ultimate project outcome is the dynamic prediction modelling for COVID-19 pandemic in Rwanda. DISCUSSION: The project is the first on the African continent leveraging AI and implementation of an OMOP CDM based federated data network for data harmonization. Such infrastructure is scalable for other pandemics monitoring, outcomes predictions, and tailored response planning.

The Role of the Integrated District Hospital Based Non Communicable Diseases' Clinics in Cardiovascular Disease Control: Preliminary Data from Rwanda.

Introduction: Noncommunicable diseases (NCDs), remain the leading cause of death worldwide and represent an emerging global health threat. In Rwanda and elsewhere, the prevalence of cardiovascular diseases is increasing. To address this global health threat, Rwanda launched integrated nurse-led NCD clinics in all the forty-five District Hospitals across the country in 2006, but no evaluation study has been conducted so far for the added value of this program. The main goal of this study was to assess the impact of NCD clinics on disease control in Rwanda. Methods: This was a retrospective ambulatory patient chart review at a rural district hospital and an urban teaching hospital; which enrolled patients with diabetes and/or hypertension who consulted in a period of 1 month with retrospective data of one year. Results: A total of 199 patients' electronic health records were reviewed from the University Teaching Hospital of Kigali (CHUK) (53%) and Nyamata District Hospital (47%). Among them, 31% had diabetes, 38% had hypertension and 31% had both diseases. The mean age for the total cohort was 60 years and was predominantly female at 70%. Throughout the year, about 59% patients with hypertension had blood pressure control at the district hospital as opposed to 38% at the referral hospital. The rate of diabetes control was 20% at the referral hospital, but no comparison could be established between the two health facilities as the follow up laboratory markers were not available at the district hospital. Conclusion: There was a consistent blood pressure control at the district hospital. Diabetes control was not optimal at the referral hospital despite the presence of human resources and logistics required for diabetes care. The situation was even worse at the district hospital where the follow up markers were rarely available.

High rates of undiagnosed and uncontrolled hypertension upon a screening campaign in rural Rwanda: a cross-sectional study.

BACKGROUND: Hypertension remains the major risk factor for cardiovascular diseases (CVDs) worldwide with a prevalence and mortality in low- and middle-income countries (LMICs) among the highest. The early detection of hypertension risk factors is a crucial pillar for CVD prevention. DESIGN AND METHOD: This cross-sectional study included 4284 subjects, mean age 46 ± 16SD, 56.4% females and mean BMI 26.6 ± 3.7 SD. Data were collected through a screening campaign in rural area of Kirehe District, Eastern of Rwanda, with the objective to characterize and examine the prevalence of elevated blood pressure (BP) and other CVD risk factors. An adapted tool from the World Health Organization STEPwise Approach was used for data collection. Elevated BP was defined as ≥ 140/90 mm/Hg and elevated blood glucose as blood glucose ≥ 100 mg/dL after a 6-h fast. RESULTS: Of the sampled population, 21.2% (n = 910) had an elevated BP at screening; BP was elevated among individuals not previously known to have HTN in 18.7% (n = 752). Among individuals with a prior diagnosis of HTN, 62.2% (n = 158 of 254) BP was uncontrolled. Age, weight, smoking, alcohol history and waist circumference were associated with BP in both univariate analyses and multivariate analysis. CONCLUSION: High rates of elevated BP identified through a health screening campaign in this Rwandan district were surprising given the rural characteristics of the district and relatively low population age. These data highlight the need to implement an adequate strategy for the prevention, diagnosis, and control of HTN that includes rural areas of Rwanda as part of a multicomponent strategy for CVD prevention.

Prevalence and incidence of arterial hypertension and its risk factors in the 7,525 person-years Congolese adult population between 2012 and 2019 : results of the Bukavu observational study.

BACKGROUND: In the Sub-Saharan African region, data on Arterial Hypertension (AHT) from longitudinal studies are scattered.This work analyzes the prevalence and incidence of AHT and its associated factors in an open cohort of Congolese adults in South Kivu. METHODS: Between 2012 and 2019, 2,633 subjects aged ≥ 15 years were monitored for at least 3 years. Baseline and follow-up included blood pressure (BP) measurements. AHT was defined as BP of at least 140/90 mmHg or intake of antihypertensive medication in patients with known AHT. Cox regression was used to analyze the association between risk factors and risk of AHT. RESULTS: The prevalence of AHT increased from 24.8% to 29.0% and the proportion of controlled hypertensive participants rose from 46.9% to 56.6% (p=0.03). During the 7,525 person-years observation period, the incidence of AHT among 1,981 participants without AHT at baseline was 19.4/1000 person-years. The annual incidence of AHT (2.4% per year) was higher in urban (5.0% per year) than in rural areas (2.0% per year). The strongest determinants for incident AHT (p<0.05) were male gender [adjusted HR (aHR)=1.67 (1.08-2.59)], age between 40-59 years [aHR=2.26 (1.48-3.45)], age ≥ 60 years [aHR=3.53 (2.11-5.93)], urban residence [aHR=3.37 (2.07-5.50)], pre-hypertension [aHR=1.77 (1.16-2.70)], abdominal obesity [aHR=1.99 (1.29-3.07)] and smoking [aHR=2.01 (1.12-3.60)]. CONCLUSION: The present study shows that the prevalence and incidence of AHT are increasing in the Congolese general population. Consequently, improved strategies for the prevention and management of non-communicable diseases are very important in Sub-Saharan Africa.

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire.

IMPORTANCE: Hypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary. OBJECTIVE: To study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool. DESIGN: A cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training. SETTING: Three tertiary care hospitals in Rwanda. PARTICIPANTS: Healthcare professionals (n=223). PRIMARY OUTCOMES AND MEASURES: The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension. RESULTS: Responders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care. CONCLUSIONS: There is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

The trend in blood pressure and hypertension prevalence in the general population of South Kivu between 2012 and 2016: Results from two representative cross-sectional surveys-The Bukavu observational study.

OBJECTIVE: Data on blood pressure trends are scarce or unavailable in Sub-Saharan Africa in general and especially in the Democratic Republic of the Congo. This work addresses this gap by analyzing the dynamics in the prevalence and control of hypertension in a cohort of Congolese adults in South Kivu. METHODS: Two phases of data collection were conducted including a baseline at the beginning in 2012 and a follow up in 2016. The subjects were ≥ 18 years old living in urban (n = 4413) or rural areas (n = 6453). Hypertension was defined as a blood pressure ≥ 140/90 mmHg and/or taking antihypertensive medications. The crude prevalence of hypertension was age-adjusted to the WHO population. RESULTS: Between 2012 and 2016, there was a significant increase in blood pressure (+2.5/+1.4 mmHg; p = 0.001), age standardized prevalence of hypertension [19.0% vs. 18.0%; OR = 1.05 (1.02-1.08); p<0.0001], and obesity (7.9% to 9.8%; p<0.0001) as well as the proportion of subjects > 60 years old (8.8% to 11.3%; p<0.0001) and those with tachycardia (10.5% to 14.4%; p<0.0001). The number of subjects under treatment of hypertension were statistically non-significant [16.1% vs. 14.3%; p = 0.29), but the level of control of hypertension was significantly reduced by 32.4% in 2016 compared in 2012 (43.5% vs. 64.4%; p = 0.0008). CONCLUSION: There was an increase in the prevalence of hypertension as well as cardiovascular-associated risk factors in the population. However, this trend did not increase for treated subjects with no improvements in the level of AHT control. Therefore, improved strategies for the prevention and management of non-communicable diseases are very important in Sub-Saharan Africa.

Roadmap to Achieve 25% Hypertension Control in Africa by 2025.

BACKGROUND: The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority action to reduce heart disease and stroke on the continent. OBJECTIVES: The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025. METHODS: Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and nonphysicians, were invited to join. Via face-to-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customized the World Heart Federation roadmap to Africa. RESULTS: Hypertension is a major crisis on the continent but very few randomized controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for management of hypertension. Other major roadblocks are either government and health-system related or health care professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025. CONCLUSIONS: Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Roadmap to achieve 25% hypertension control in Africa by 2025.

BACKGROUND AND AIM: The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority for action to reduce heart disease and stroke on the continent. The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025. METHODS: Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and non-physicians, were invited to join. Via faceto-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customised the World Heart Federation roadmap to Africa. RESULTS: Hypertension is a major crisis on the continent but very few randomised, controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for the management of hypertension. Other major roadblocks are either government and health-system related or healthcare professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025. CONCLUSIONS: Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Obesity and diabetes mellitus association in rural community of Katana, South Kivu, in Eastern Democratic Republic of Congo: Bukavu Observ Cohort Study Results.

BACKGROUND: Factual data exploring the relationship between obesity and diabetes mellitus prevalence from rural areas of sub-Saharan Africa remain scattered and are unreliable. To address this scarceness, this work reports population study data describing the relationship between the obesity and the diabetes mellitus in the general population of the rural area of Katana (South Kivu in the Democratic Republic of the Congo). METHODS: A cohort of three thousand, nine hundred, and sixty-two (3962) adults (>15 years old) were followed between 2012 and 2015 (or 4105 person-years during the observation period), and data were collected using the locally adjusted World Health Organization's (WHO) STEPwise approach to Surveillance (STEPS) methodology. The hazard ratio for progression of obesity was calculated. The association between diabetes mellitus and obesity was analyzed with logistic regression. RESULTS: The diabetes mellitus prevalence was 2.8 % versus 3.5 % for obese participants and 7.2 % for those with metabolic syndrome, respectively. Within the diabetes group, 26.9 % had above-normal waist circumference and only 9.8 % were obese. During the median follow-up period of 2 years, the incidence of obesity was 535/100,000 person-years. During the follow-up, the prevalence of abdominal obesity significantly increased by 23 % (p <0.0001), whereas the increased prevalence of general obesity (7.8 %) was not significant (p = 0.53). Finally, diabetes mellitus was independently associated with age, waist circumference, and blood pressure but not body mass index. CONCLUSION: This study confirms an association between diabetes mellitus and abdominal obesity but not with general obesity. On the other hand, the rapid increase in abdominal obesity prevalence in this rural area population within the follow-up period calls for the urgent promoting of preventive lifestyle measures.

Semantic processing of EHR data for clinical research.

There is a growing need to semantically process and integrate clinical data from different sources for clinical research. This paper presents an approach to integrate EHRs from heterogeneous resources and generate integrated data in different data formats or semantics to support various clinical research applications. The proposed approach builds semantic data virtualization layers on top of data sources, which generate data in the requested semantics or formats on demand. This approach avoids upfront dumping to and synchronizing of the data with various representations. Data from different EHR systems are first mapped to RDF data with source semantics, and then converted to representations with harmonized domain semantics where domain ontologies and terminologies are used to improve reusability. It is also possible to further convert data to application semantics and store the converted results in clinical research databases, e.g. i2b2, OMOP, to support different clinical research settings. Semantic conversions between different representations are explicitly expressed using N3 rules and executed by an N3 Reasoner (EYE), which can also generate proofs of the conversion processes. The solution presented in this paper has been applied to real-world applications that process large scale EHR data.

Sublingual misoprostol versus intramuscular oxytocin for prevention of postpartum hemorrhage in Uganda: a double-blind randomized non-inferiority trial.

BACKGROUND: Postpartum hemorrhage (PPH) is a leading cause of maternal death in sub-Saharan Africa. Although the World Health Organization recommends use of oxytocin for prevention of PPH, misoprostol use is increasingly common owing to advantages in shelf life and potential for sublingual administration. There is a lack of data about the comparative efficacy of oxytocin and sublingual misoprostol, particularly at the recommended dose of 600 µg, for prevention of PPH during active management of labor. METHODS AND FINDINGS: We performed a double-blind, double-dummy randomized controlled non-inferiority trial between 23 September 2012 and 9 September 2013 at Mbarara Regional Referral Hospital in Uganda. We randomized 1,140 women to receive 600 µg of misoprostol sublingually or 10 IU of oxytocin intramuscularly, along with matching placebos for the treatment they did not receive. Our primary outcome of interest was PPH, defined as measured blood loss ≥ 500 ml within 24 h of delivery. Secondary outcomes included measured blood loss ≥ 1,000 ml; mean measured blood loss at 1, 2, and 24 h after delivery; death; requirement for blood transfusion; hemoglobin changes; and use of additional uterotonics. At 24 h postpartum, primary PPH occurred in 163 (28.6%) participants in the misoprostol group and 99 (17.4%) participants in the oxytocin group (relative risk [RR] 1.64, 95% CI 1.32 to 2.05, p<0.001; absolute risk difference 11.2%, 95% CI 6.44 to 16.1). Severe PPH occurred in 20 (3.6%) and 15 (2.7%) participants in the misoprostol and oxytocin groups, respectively (RR 1.33, 95% CI 0.69 to 2.58, p = 0.391; absolute risk difference 0.9%, 95% CI -1.12 to 2.88). Mean measured blood loss was 341.5 ml (standard deviation [SD] 206.2) and 304.2 ml (SD 190.8, p = 0.002) at 2 h and 484.7 ml (SD 213.3) and 432.8 ml (SD 203.5, p<0.001) at 24 h in the misoprostol and oxytocin groups, respectively. There were no significant differences between the two groups in any other secondary outcomes. Women in the misoprostol group more commonly experienced shivering (RR 1.91, 95% CI 1.65 to 2.21, p<0.001) and fevers (RR 5.20, 95% CI 3.15 to 7.21, p = 0.005). This study was conducted at a regional referral hospital with capacity for emergency surgery and blood transfusion. High-risk women were excluded from participation. CONCLUSIONS: Misoprostol 600 µg is inferior to oxytocin 10 IU for prevention of primary PPH in active management of labor. These data support use of oxytocin in settings where it is available. While not powered to do so, the study found no significant differences in rate of severe PPH, need for blood transfusion, postpartum hemoglobin, change in hemoglobin, or use of additional uterotonics between study groups. Further research should focus on clarifying whether and in which sub-populations use of oxytocin would be preferred over sublingual misoprostol. TRIAL REGISTRATION: ClinicalTrials.gov NCT01866241 Please see later in the article for the Editors' Summary.

Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings.

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Current and projected prevalence of arterial hypertension in sub-Saharan Africa by sex, age and habitat: an estimate from population studies.

INTRODUCTION: In sub-Saharan Africa (SSA), data on hypertension prevalence in terms of urban or rural and sex difference are lacking, heterogeneous or contradictory. In addition, there are no accurate estimates of hypertension burden. OBJECTIVE: To estimate the age-specific and sex-specific prevalence of arterial hypertension in SSA in urban and rural adult populations. METHODS: We searched for population studies, conducted from 1998 through 2008 in SSA. We extracted data from selected studies on available prevalences and used a logistic regression model to estimate all age/sex/habitat (urban/rural)/country-specific prevalences for SSA up to 2008 and 2025. On the basis of the United Nations Population Fund data for 2008 and predictions for 2025, we estimated the number of hypertensives in both years. RESULTS: Seventeen studies pertaining to 11 countries were analysed. The overall prevalence rate of hypertension in SSA for 2008 was estimated at 16.2% [95% confidence interval (CI) 14.1-20.3], ranging from 10.6% in Ethiopia to 26.9% in Ghana. The estimated prevalence was 13.7% in rural areas, 20.7% in urban areas, 16.8% in males, and 15.7% in women. The total number of hypertensives in SSA was estimated at 75 million (95% CI 65-93 million) in 2008 and at 125.5 million (95% CI 111.0-162.9 million) by 2025. CONCLUSION: The estimated number of hypertensives in 2008 is nearly four times higher than the last (2005) estimate of the World Health Organization Regional Office for Africa. Prevalences were significantly higher in urban than in rural populations. Population data are lacking in many countries underlining the need for national surveys.

Evaluation of medication adherence methods in the treatment of malaria in Rwandan infants.

OBJECTIVES: To compare three methods for evaluating treatment adherence in a 7-day controlled treatment period for malaria in children in Rwanda. METHODS: Fifty-six children (< 5 years) with malaria were recruited at the University Hospital of Butare, Rwanda. Patients were treated with quinine sulfate, taste-masked, pellets during seven days: three days in hospital (in-patient) followed by a four-day out-patient period. Three methods to evaluate medication adherence among patients were compared: manual pill count of returned tablets, patient self-report and electronic pill-box monitoring. These pill-boxes were equipped with a microchip registering date and time of every opening. Medication adherence was defined as the proportion of prescribed doses taken. The inter-dose intervals were analysed as well. RESULTS: Medication adherence data were available for 54 of the 56 patients. Manual pill count and patient self-report yielded a medication adherence of 100% for the in- and out-patient treatment periods. Based on electronic pill-box monitoring, medication adherence during the seven-day treatment period was 90.5 +/- 8.3%. Based on electronic pill-box monitoring inpatient medication adherence (99.3 +/- 2.7%) was markedly higher (p < 0.03) than out-patient adherence (82.7 +/- 14.7%), showing a clear difference between health workers' and consumers' medication adherence. CONCLUSION: Health workers' medication adherence was good. However, a significant lower medication adherence was observed for consumers' adherence in the outpatient setting. This was only detected by electronic pill-box monitoring. Therefore, this latter method is more accurate than the two other methods used in this study.

Prices of antihypertensive medicines in sub-Saharan Africa and alignment to WHO's model list of essential medicines.

OBJECTIVE: To investigate compliance of National Essential Medicines Lists (NEMLs) with the WHO Essential Medicines List (WHO/EML) in 2007 and to compare prices of antihypertensive drugs in and between 13 sub-Saharan African countries. METHODOLOGY: Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies (five of each per country). Prices were compared with the International Drug Price Indicator Guide (IDPIG). The cost of drug treatment within a country was calculated using defined daily doses (DDD) and between countries using DDD prices adjusted for purchasing power parity-based gross domestic product per capita. RESULTS: All surveyed countries had a NEML. However, none of these lists were in complete alignment with the 2007 WHO/EML, and 38% had not been updated in the last 5 years. Surveyed medicines were cheaper when on the NEMLs; they were also cheaper in public than in private pharmacies. Prices varied greatly per medicine. A large majority of the public prices were higher than those indicated by the IDPIG. Overall, hydrochlorothiazide is the cheapest drug. CONCLUSION: There are substantial differences in NEML composition between the 13 countries. The proportion of NEMLs not regularly updated was double the global United Nations estimates. Prices of WHO/EML-advised drugs differ greatly between drugs and for each drug within and between countries. In general, the use of drugs on the NEML improves financial accessibility, and these drugs should be prescribed preferentially.

Influence of tropical climate conditions on the quality of antihypertensive drugs from Rwandan pharmacies.

The objective of this study was to assess the quality of antihypertensive drugs and to investigate the influence of tropical storage conditions. Drug content and in vitro dissolution tests were performed on 10 test formulations (from Rwanda) and 6 reference formulations (from Belgium or France) after purchase and after 6-month storage under long-term (25 +/- 2 degrees C and 60 +/- 5% relative humidity [RH]) and accelerated (40 +/- 2 degrees C and 75 +/- 5% RH) testing conditions. Twenty percent of test formulations were of substandard content at the time of purchase. After 6 months at accelerated testing conditions, 7 of 10 test formulations were substandard in content and 8 were substandard for the combined criteria of drug content and dissolution, whereas no reference drug became substandard. This study shows that, apart from some drugs being already substandard from purchase, accelerated testing conditions (simulating tropical climate) have deleterious effects on the majority of antihypertensive drug formulations found in the Rwandan market.

Inhospital cardiovascular morbidity and mortality in the department of internal medicine at CHU Kigali (Rwanda)

Cardiovascular diseases (CVD) formerly considered as developed countries pandemic, are becoming nowadays increasingly ubiquitous in developing countries, where in addition to a steady increase in different risk factors, there is substantial inaccessibility to health care. However, data about the burden of CVD is lacking in many sub-Saharan African countries, and their morbimortality characteristics have been poorly described. Authors carried out a descriptive and retrospective study over a 12-month period, to describe the inhospital morbidity and mortality of CVD in the Department of Internal Medicine at University Teaching Hospital in Kigali City. Data were collected from 226 CVD cases (91 males and 135 females). The patients' age ranged from 26 to 94 years (mean age of 47.17 ± 16.04). The 226 CVD cases account for the 8.2% of hospitalized patients. Hypertension was the principal cause of death (43.1% of deaths) and the predominant cause of patients' admission (42.9%), followed by cardiomyopathies (11.9%) and valvular heart diseases (11.5%). The association between a CVD and HIV/AIDS infection was observed in 23.9% of the total patients, but no causality relationship was investigated. Isolated heart failure takes the first place (33.6%) among the cardiovascular complications, followed by stroke (14.2%) and isolated renal failure (7.5%). Findings of this study confirm the importance of CVD in CHU Kigali, not only by their inhospital frequency but also- and especially by their lethality rate and their complications associated. This study stresses also a real need of CVD community survey in Rwanda

Prevalence of dilated cardiomyopathy in HIV-infected African patients not receiving HAART: a multicenter, observational, prospective, cohort study in Rwanda.

INTRODUCTION: Several studies performed before the introduction of highly active antiretroviral therapy (HAART) have shown that HIV-1 infection is an important cause of dilated cardiomyopathy. However, factors associated with the development of HIV-associated cardiomyopathy in developing countries are still debated. OBJECTIVES: To assess the prevalence of dilated cardiomyopathy, diagnosed by echocardiography, in HIV-infected Rwandese patients not receiving HAART and the risk factors associated with its development. METHODS: A sample of 416 HIV-infected african patients, without a previous definite history of cardiovascular disease, attending University hospitals in Rwanda, from January to December 2005, were included in a multicenter, observational, prospective, cohort study, with the collaboration of two European Clinical Centers (in France and in Italy). Clinical and laboratory tests along with echocardiographic examination were performed in all patients included in the study. RESULTS: Out of 416 patients included in the study, dilated cardiomyopathy was documented by echocardiography in 71 (17.7%). By both univariate and multivariate analysis, low socio-economic status, estimated duration of HIV-1 infection, CD4 count, HIV-1 viral load, CDC stage B and C of HIV disease and low plasmatic level of selenium were factors significantly associated with the development of cardiomyopathy. Alcohol consumption and smoking were factors associated with the development of cardiomyopathy only by univariate analysis. CONCLUSIONS: HIV-associated cardiomyopathy is a significant clinical problem in HIV-infected patients not receiving HAART in Rwanda. Early tracking of cardiomyopathy in African HIV-infected patients is therefore recommended. Before administering HAART, clinicians should be aware of a possible existing cardiomyopathy to ensure appropriate, comprehensive, and rational patient care.