Proximal deep vein thrombosis among hospitalised medical and obstetric patients in Rwandan university teaching hospitals: prevalence and associated risk factors: a cross-sectional study.

OBJECTIVES: To determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics-gynaecology inpatients in two Rwandan tertiary hospitals. DESIGN: Cross-sectional study. SETTINGS: Rwanda teaching hospitals: Kigali and Butare University Teaching Hospitals. PARTICIPANTS: 901 adult patients admitted to the Departments of Internal Medicine and Obstetrics-Gynecology (O&G) who were at least 21 years of age and willing to provide a consent. OUTCOMES: Prevalence of proximal DVT, clinical features and known risk factors associated with DVT. METHODS: Between August 2015 and August 2016, participants were screened for DVT by compressive ultrasound of femoral and popliteal veins, conducted as a monthly cross-sectional survey of all consenting eligible inpatients. Patients completed a self-report survey on DVT risk factors. Prevalence of proximal DVT by compression ultrasonography was the primary endpoint, with univariate and multivariate regression analyses performed to assess associated clinical features and risk factors. RESULTS: Proximal DVT was found in 5.5% of the study population, with similar rates in medical and O&G inpatients. The mean age was 41±16 SD (range, 21-91), 70% were female and 7% were pregnant. Univariate analysis showed active malignancy, immobilisation, prolonged recent travel and history of DVT to be significant risk factors for proximal DVT (all p values <0.05); while only active malignancy was an independent risk factor on multivariate regression (OR 5.2; 95% CI 2.0 to 13). Leg pain or tenderness, increased calf circumference, unilateral limb swelling or pitting oedema were predictive clinical features of DVT on both univariate analysis and multivariate regression (all p values <0.05). CONCLUSION: Proximal DVT prevalence is high among hospitalised medical and O&G patients in two tertiary hospitals in Rwanda. For reducing morbidity and mortality, research to develop Africa-specific clinical prediction tools for DVT and interventions to increase thromboprophylaxis use in the region are urgently needed.

Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda.

OBJECTIVE: Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy. The majority of US teaching medical institutions have incorporated them into clinical training. Many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. We sought to determine the utility of EBCRs in an East African medical school. SETTING: The University of Rwanda (UR), a medical school located in East Africa. PARTICIPANTS: Medical students and faculty members at UR. INTERVENTIONS: We offered medical students and faculty at UR free access to UpToDate, a leading EBCR and conducted a cohort study to assess its uptake and usage. Students completed two surveys on their study habits and gave us permission to access their activity on UpToDate and their grades. RESULTS: Of the 980 medical students invited to enrol over 2 years, 547 did (56%). Of eligible final year students, 88% enrolled. At baseline, 92% of students reported ownership of an internet-capable device, and the majority indicated using free online resources frequently for medical education. Enrolled final year students viewed, on average, 1.24 topics per day and continued to use UpToDate frequently after graduation from medical school. Graduating class exam performance was better after introduction of UpToDate than in previous years. CONCLUSIONS: Removal of the cost barrier was sufficient to generate high uptake of a leading EBCR by senior medical students and habituate them to continued usage after graduation.

Low prevalence of hepatitis C virus RNA in blood donors with anti-hepatitis C virus reactivity in Rwanda.

BACKGROUND: Hepatitis C virus (HCV) is the leading cause of severe liver disease worldwide and is highly endemic in Africa, where it often has nosocomial spread. Little is known on the HCV prevalence, risk for transfusion-transmitted HCV, and circulating genotypes in Rwanda. This study was performed to investigate the prevalence of anti-HCV among blood donors from all regions of the country and genetically characterize identified HCV strains. STUDY DESIGN AND METHODS: Data on anti-HCV reactivity for all 45,061 Rwandan blood donations during 2014 were compiled. Samples from 720 blood donors were reanalyzed for anti-HCV in Sweden. Line immunoassay INNO-LIA HCV and detection of HCV RNA by polymerase chain reaction were used to confirm anti-HCV reactivity. The NS5B and core regions were sequenced and phylogenetic analysis was performed. RESULTS: The anti-HCV prevalence among all first-time blood donors was 1.6%, with the highest occurrence in donors from the eastern region. On further analysis, only 25 of 120 primarily anti-HCV-reactive samples could be confirmed reactive and 15 samples had indeterminate results by INNO-LIA. Confirmed reactivity was more common among females than males (p = 0.03) with no regional difference. Phylogenetic analysis of the sequences showed a predominance of subtypes 4k, 4q, and 4r, with no geographical difference in their distribution. CONCLUSION: The prevalence of anti-HCV among Rwandan blood donors has probably been overestimated previously due to the high rate of nonconfirmable anti-HCV reactivity. Further study of the involved mechanism is needed to avoid loss of blood products and distress for blood donors and other test recipients.

"Waiting for DAAs": A retrospective chart review of patients with untreated hepatitis C in Rwanda.

BACKGROUND: Access to treatment for hepatitis C virus (HCV) in sub-Saharan Africa is extremely limited. With the advent of direct acting antivirals (DAAs), highly effective and easy-to-deliver oral regimens are now available on the global market. This study was conducted to understand the background and characteristics of a national cohort of patients with HCV infection enrolled in care and awaiting therapy with DAAs. METHODS AND FINDINGS: We conducted a retrospective chart review of all adult patients with confirmed HCV infection who were currently enrolled in care and treatment at the four existing hepatitis referral centers in Rwanda. Patient charts at these centers were reviewed, and routinely collected data were recorded and analyzed. Overall, 253 patients were identified; median age was 56 years (IQR: 43, 65), and 149 (58.9%) were female. Median viral load was 688,736 IU/ml and 96.7% were HCV genotype 4. As classified by FIB-4 score, 64.8% of the patients had moderate to severe fibrosis. Fibrosis stage was associated with age (OR 1.12, CI 1.09-1.17), but not with time since diagnosis, gender, treatment center, or type of insurance. There was a low frequency of documented co-morbid conditions, including hypertension, diabetes, HIV, and hepatitis B virus. CONCLUSIONS: Compared to an estimated 55,000 patients eligible for HCV treatment in Rwanda, this study identified only 253 patients currently diagnosed and engaged in care, highlighting an immense treatment gap in HCV, likely due to the lack of accessible and affordable screening, diagnostic, and treatment modalities. The patients that were enrolled in care had a disproportionately advanced fibrosis stage, possibly indicating late presentation to care or lack of treatment options. In the context of newly available and effective treatment options, this study supports the overall need to accelerate access to HCV screening, diagnostics, and care and treatment services in resource-limited settings in sub-Saharan Africa.

Effects of a lifestyle education program on glycemic control among patients with diabetes at Kigali University Hospital, Rwanda: A randomized controlled trial.

AIM: Evidence to show whether lifestyle intervention programs are beneficial for patients with diabetes in resource-limited countries is lacking. The present study assessed the additional efficacy of a structured lifestyle education program, as compared to the current standard of diabetic care in Rwanda. METHODS: 251 consecutive adult patients attending a tertiary diabetic care practice were randomly assigned to either an intervention group (standard of care plus monthly lifestyle group education sessions of 45min duration) or to a control group. The primary outcome was between-groups difference in glycated hemoglobin (HbA1c) observed after 12-months follow up. Outcome measures in the intervention and control groups were compared using the ANCOVA test with a two-sided significance of 5%. RESULTS: Of the 251 subjects recruited, 223 were included in the analysis; of whom 115 were assigned to the intervention group, and 108 to the control group. After 12-months, the median HbA1c levels reduced by 1.70 (95% CI: -2.09 to -1.31; p<0.001) in the intervention group; and by 0.52 (95% CI: -0.95 to -0.10; p=0.01) in the control group. The difference in HbA1c reduction between the intervention and control groups was statistically significant (p<0.001) after adjustment for subjects' age, sex, education level, BMI, diabetes duration and diabetic medications. CONCLUSIONS: This study demonstrated that a structured lifestyle group education program for people with diabetes is an attractive option in a resource-limited setting, as it showed significant benefits in improved glycemic control over a 12-month period. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02032108.

Hepatitis B virus strains from Rwandan blood donors are genetically similar and form one clade within subgenotype A1.

BACKGROUND: Rwanda is a central African country with about 12 million inhabitants. The 1994 genocide against the Tutsi destroyed much of the infrastructure, including the health system. Although this has improved significantly, many challenges remain to be addressed. In this study, the prevalence of serological markers of past and ongoing hepatitis B virus (HBV) infection and HBV vaccine related immunity was investigated in samples from blood donors from all regions of Rwanda. METHODS: The results from hepatitis B surface antigen (HBsAg) analyses of all (45,061) blood donations collected countrywide in 2014 from 13,637 first time and 31,424 repeat blood donors were compiled. Samples from 581 HBsAg negative blood donors were selected for further analysis for antibodies against HBV, anti-HBs and anti-HBc. Additional 139 samples from HBsAg positive donors were analyzed for HBeAg/anti-HBe (132 samples) and for HBV DNA. The S-gene was amplified by PCR, products sequenced, and phylogenetic analysis was performed. RESULTS: HBsAg was found in 4.1% of first time donors with somewhat higher prevalence among those from the Central and Eastern regions than from other parts of the country. Indications of past infection was found in 21% of the HBsAg negative donors, 4.3% had only anti-HBs suggesting HBV vaccination. HBeAg was detected in 28 (21%), anti-HBe in 97 (73%), and both HBeAg and anti-HBe in 4 of 132 HBsAg positive donors. HBV DNA was found in 85 samples, and the complete S-gene was sequenced in 58 of those. Phylogenetic analysis of the sequences revealed that all HBV strains belonged to subgenotype A1, and formed one clade in the phylogenetic tree. In addition, 12 strains from first time donors had a unique 18 amino acid deletion in the N-terminal part of the pre-S2 region. CONCLUSION: This study indicated that the prevalence of hepatitis B is intermediate in Rwanda and that the vaccination coverage is relatively low in young adults. All surveyed Rwandan blood donors were infected with similar subgenotype A1 strains, and a high frequency of those with anti-HBe had detectable HBV DNA. Several strains had in addition a unique pre-S2 deletion, the virulence of which needs to be further studied.

Evaluation of adherence to a convulsion management protocol for children in Rwanda.

Inappropriate seizure management may result in high morbidity and mortality. We assessed the adherence of health professionals in southern Rwanda to a national protocol for pharmacological management of seizures in children. A questionnaire featuring a 5-year-old child with generalized prolonged seizures was administered. The questions focused on the choice of initial treatment and the sequence of management following failure of the initial treatment choice. Benzodiazepine was chosen as initial therapy by 93.7% of physicians and 90.9% of nurses. Only 49.2% of physicians and 41% of nurses would repeat the initial treatment in case of failure of the first dose and 47% of doctors would wait 30 min to intervene. In case of refractory status epilepticus, 34% of physicians would give three doses of benzodiazepine, whereas 19% did not know what to do. These results suggest poor adherence to national protocol.

Efficacy of sublingual lorazepam versus intrarectal diazepam for prolonged convulsions in Sub-Saharan Africa.

In Sub-Saharan Africa, intrarectal diazepam is the first-line anticonvulsant mostly used in children. We aimed to assess this standard care against sublingual lorazepam, a medication potentially as effective and safe, but easier to administer. A randomized controlled trial was conducted in the pediatric emergency departments of 9 hospitals. A total of 436 children aged 5 months to 10 years with convulsions persisting for more than 5 minutes were assigned to receive intrarectal diazepam (0.5 mg/kg, n = 202) or sublingual lorazepam (0.1 mg/kg, n = 234). Sublingual lorazepam stopped seizures within 10 minutes of administration in 56% of children compared with intrarectal diazepam in 79% (P < .001). The probability of treatment failure is higher in case of sublingual lorazepam use (OR = 2.95, 95% CI = 1.91-4.55). Sublingual lorazepam is less efficacious in stopping pediatric seizures than intrarectal diazepam, and intrarectal diazepam should thus be preferred as a first-line medication in this setting.