Non-surgical Adult Male Circumcision Using the PrePex Device: Task-Shifting from Physicians to Nurses

The Republic of Rwanda is implementing a program of voluntary male circumcision (MC) to reduce HIV transmission but lacks the infrastructure for conventional surgical MC on a nationwide scale. Nonsurgical MC using the PrePex device was first assessed in 5 subjects on an inpatient basis. Subsequent procedures were on an outpatient basis. Physicians performed 100 outpatient procedures (Phase 1 of this study) and trained nurses in the technique; the nurses then independently performed 47 procedures (Phase 2). All subjects achieved complete circumcision and healing within 6 weeks. There were no cases of infection or bleeding. In Phase 1, one case of transient moderate diffuse edema occurred. In Phase 2, no adverse events were reported. Thus, outcomes of MC performed by nurses using the PrePex device were not inferior to outcomes achieved by physicians, suggesting that task-shifting MC by this method from physicians to nurses is feasible in Rwanda. (Afr J Reprod Health 2014; 18[1]: 61-70).Keywords: Circumcision, device, nurses, Rwanda, safety, task-shiftin

Converging Currents in Climate-Relevant Conservation: Water, Infrastructure, and Institutions

Ecologists and economists have long talked past each other, but climate change presents similar threats to both groups. Water may serve as the best means of finding a common cause and building a new vision of ecological and economic sustainability, especially in the developing world

Management Challenges Of Pediatric Infective Endocarditis At Tertiary Level In Rwanda

Background: Management of Infective Endocarditis (IE) has been of great challenge for many years. Rapid diagnosis, effective treatment, and prompt recognition of complications are essential to good patient outcome as this condition is associated with a high morbidity and mortality in both adults and pediatric patients. In limited resources settings, management of IE is still a challenge due to early inappropriate antibiotherapy and therefore difficulties in its diagnosis and treatment. Objectives: To elicit challenges in management of patients suspected of IE at tertiary level in Rwanda. Methods: We report four patients with IE. For these patients, Duke’s criteria were considered in making the diagnosis. Results and Conclusion: IE has protean clinical symptoms and signs, and can be of challenging diagnosis. The patients reported constituted a clinical challenge in the diagnosis and management of IE but most of them had had favorable outcome. The main clinical challenge was the prolonged stay to peripheral settings with inappropriate antibiotherapy which made most of the blood cultures falsely negative. Echocardiography and serial blood cultures provide the key to diagnosis as per Dukes criteria. Being alert to this mentioned challenge is crucial. As the key investigations are not steadily available in most peripheral health facilities, we strongly recommend early referral to tertiary level for all cases of suspected IE before initiation of antibiotherapy.Introduction: Depuis plusieurs années, la prise en charge de l’endocardite bactérienne constitue un grand défi. Cette affection étant associée à une importante morbidité et mortalité tant chez l’adulte que chez l’enfant, un diagnostic rapide, un traitement efficace, et une reconnaissance rapide de complications sont des éléments essentiels pour arriver à un bon résultat thérapeutique. Dans les pays où les ressources sont limitées, la prise en charge de l’endocardite reste difficile en raison de l’antibiothérapie inappropriée initiée préalablement au niveau des structures sanitaires de base. Objectif: Identifier les défis dans la prise en charge des patients présentant une endocardite bactérienne au niveau des structures sanitaires tertiaires du Rwanda. Méthodes: Nous rapportons quatre patients qui présentaient une endocardite bactérienne. Pour tous ces patients, les critères de Duke ont été utilisés pour poser le diagnostic. Résultats et conclusion: L’endocardite infectieuse a des formes cliniques variables et peut rendre le diagnostic difficile. Bien que presque tous les patients reportés dans cette étude ont été traités avec succès, leur prise en charge n’a pas été facile d’emblée. Le plus grand défi a été un séjour prolongé sous antibiothérapie probabiliste a l’Hôpital de District, ce qui a rendu la plupart des hémocultures faussement négatives au niveau tertiaire. L’échocardiographie et une série d’au moins 3 hémocultures constituent les éléments clés des critères de Duke pour le diagnostic de l’endocardite bactérienne. Par conséquent, il est crucial pour les cliniciens de tenir compte de ces critères pour poser le diagnostic d’endocardite. Compte tenu de l’absence de moyens pour faire les hémocultures et une échocardiographie au niveau des hôpitaux de district, nous recommandons un transfert rapide au niveau de l’hôpital de référence pour tout cas suspect d’endocardite bactérienne avant d’initier l’antibiothérapie

Patients With Noonan Syndrome Phenotype: Spectrum Of Clinical Features And Congenital Heart Defect

Mutations in components of the RAS-MAPK signaling pathway have been reported to result in an expression of Noonan phenotype. This is actually a wide-spectrum-phenotype shared by Noonan syndrome and its clinically related disorders namely, the Cranio-facio-cutaneous (CFC) syndrome, Costillo syndrome as well as LEOPARD syndrome. Patients with Noonan Syndrome (NS) have mutations in PTPN11 gene in majority of cases. Recently, mutations in SOS1, RAF1, MEK1 and KRAS genes have been reported to cause NS as well. Objective: To report patients with a Noonan phenotype followed in Rwandan University Teaching Hospitals, and to show the importance of the clinical diagnosis and challenges of making the diagnosis in resource limited settings where karyotype is almost the only genetic investigation accessible. Patients and Methods: Here we are reporting 5 patients, all with relevant NS symptoms, whose morbidity is directly related to the severity of their congenital heart disease. Van der burgt et al diagnostic criteria have been used for the clinical diagnosis, karyotype studies have been performed to exclude chromosomal aberration disorders and patients DNA extraction for mutation studies have been obtained in some cases. Results and Conclusion: we identified 5 patients with clinical features highly suggestive of NS and all of them had a normal karyotype, this excluding Turner syndrome, a clinically similar syndrome. As there are many as yet discovered mutations causing NS and the famous PTPN11 mutation being present only in 50% of cases, we maintain here that NS diagnosis should be a clinical diagnosis. The morbidity and mortality of our patients were directly correlated to the severity of their congenital cardiac defect. In conclusion, early management of such patients is highly recommended.Les mutations impliquant la voie de transduction RAS-MAPK ont étaient reconnues identifiées comme causant un « phénotype du syndrome Noonan ». Ceci est en effet un phénotype de spectre très large, partagé entre le syndrome de Noonan et d’autres conditions cliniquement semblable notamment le syndrome Crânio-Facio-Cutané (CFC), le syndrome de Costillo ainsi que le syndrome de LEOPARD. Les patients atteints du syndrome de Noonan ont des mutations dans le gène PTPN11 dans la majorité des cas. Récemment, les mutations impliquant les gènes SOS1, RAF1, MEK1 et KRAS ont étaient caractérisées comme étant aussi impliquées dans le développement du syndrome de Noonan. Objectifs: rapporter des patients atteints du syndrome de Noonan suivis dans nos hôpitaux universitaires et montrer l’importance du diagnostic clinique ainsi que le défi à faire le diagnostique dans un contexte où les ressources sont limitées, seul le karyotype étant presque le test génétique accessible. Résultats et Conclusion nous avons identifié 5 patients avec un tableau clinique suggestif du syndrome de Noonan et chez qui le karyotype a été normal, ceci excluant le syndrome de Turner qui mime la clinique du syndrome de Noonan. Compte tenu du fait qu’il y a beaucoup de mutations causant le syndrome de Noonan et les mutation du gène PTPN11 n’étant présentes que dans 50% des cas, nous plaidons pour l’importance du diagnostique clinique. La morbidité et mortalité des patients signalés dans cette revue étaient directement liées à la sévérité de leurs cardiopathies congénitales. En conclusion, une prise en charge précoce de tels patients devrait être recommandée

Information Systems For Monitoring The Burden Of Chronic Diseases In Public Reference Health Facilities In Rwanda, Burundi And Eastern Drc

Chronic diseases are an increasingly important cause of death in sub-Saharan Africa. Diseases such as cancer, diabetes and arterial hypertension remained for years in the background, in the shadow of pandemics such as malaria, HIV / AIDS and tuberculosis. In the past 6 years, 4 reference hospitals of Kisangani, Bukavu, Kigali and Bujumbura implemented hospital information systems enabling sophisticated analysis of the diagnostic variance of out-patient visits and in-patient admissions. Important volumes of chronic disease data have been collected in a period between 2006 and 2012, demonstrating that the problem of chronic diseases also grows rapidly in the Great Lakes region and therefore urgent steps must be taken, both by governments (Rwanda, DRC and Burundi), by the international donor community and by local hospital boards.Les maladies chroniques sont une cause de décès de plus en plus importante en Afrique sub-saharienne. Les maladies telles que le cancer, le diabète et l’hypertension artérielle sont restées pendant des années dans le fond, dans l’ombre de pandémies telles que le paludisme, le VIH / SIDA et la tuberculose. Au cours des 6 dernières années, 4 hôpitaux de référence de Bujumbura, Kisangani, Bukavu et Kigali ont implémenté des systèmes de gestion d’informations hospitalières permettant l’analyse sophistiquée de la variance diagnostique aussi bien en ambulatoire qu’en hospitalisation. Des volumes importants de données sur les maladies chroniques ont été rassemblées dans la période entre 2006 et 2012, démontrant que le problème des maladies chroniques gagne rapidement en importance dans la région des Grands Lacs et que des mesures urgentes doivent être prises, tant par les gouvernements (Rwanda, RDC et Burundi), par la communauté internationale des bailleurs de fonds et par les gestionnaires des hôpitaux

Request for Antimalarial Medicines and Their Dispensing Without a Prescription in Community Pharmacies in Rwanda

Amon Nsengimana,1 Emmanuel Biracyaza,2,3 Joyce Isimbi,4 Charles Uwambajimana,4 Jean Claude Hategekimana,4 Vedaste Kagisha,4 Domina Asingizwe,5,6 Jean Baptiste Nyandwi4,6 1US Agency for International Development Global Health Supply Chain Program, Procurement and Supply Chain Management, Kigali, Rwanda; 2School of Rehabilitation, Faculty of Medicine, Université de Montréal, Québec, Canada; 3Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Canada; 4Department of Pharmacy, University of Rwanda, Kigali, Rwanda; 5Department of Physiotherapy; University of Rwanda, Kigali, Rwanda; 6East African Community Regional Centre of Excellence for Vaccines, Immunization and Health Supply Chain Management, University of Rwanda, Kigali, RwandaCorrespondence: Amon Nsengimana, Email [email protected]: This study aimed to explore the request and dispensing of antimalarial medicines without a prescription in community pharmacies in Rwanda, as well as factors associated.Methods: We employed an embedded mixed-methods design that involved a convenience sample of 235 licensed community pharmacists between February and April 2022. To simultaneously collect qualitative and quantitative data, we used a self-administered questionnaire containing a combination of close and open-ended questions. Bivariate and multivariate regression analyses were performed to examine the relationship between dispensing antimalarial medicines without a prescription and the selected independent variables. Statistical significance was set at p< 0.05, and a 95% confidence interval was applied. The factors influencing the dispensing of antimalarial medicines without a prescription were analyzed using thematic content analysis as a qualitative analysis approach.Results: Most respondents (88.5%) were asked to dispense antimalarial medicines by clients without a prescription. More than half of them (54%) agreed, but 34.5% refused; instead, they referred clients to malaria diagnostic testing facilities. Those who had rapid diagnostic tests for malaria in stock (OR=2.08, 95% CI:1.1– 3.94), and thought that antimalarials were over-the-counter medicines (OR=7.03, 95% CI:2.01– 24.5) were more likely to dispense antimalarial medicines without prescriptions. The primary reasons reported by community pharmacists for dispensing antimalarial medicines without prescriptions included their prior knowledge of malaria diagnosis, client pressure, and fear of losing clients. However, non-adherence to negative results obtained from formal health facilities and long queues at these institutions have also been cited as additional factors driving clients to seek antimalarial medicines without prescriptions.Conclusion: Dispensing antimalarial medicines without prescriptions is a common practice in community pharmacies in Rwanda. The main factors contributing to this practice include lack of awareness regarding the classification of antimalarials as prescription medicines, the availability of malaria diagnostic tests, client pressure, and fear of losing clients.Keywords: request, antimalarial medicines, dispensing, community pharmacies, Rwand