Outcome of paediatric supracondylar humeral fractures treated by surgery at the University Teaching Hospital of Kigali, Rwanda

Background: Supracondylar humeral fractures are common elbow injuries in children. When these fractures are managed improperly, patients end up having complications that interfere with daily activities. Objective: This study was conducted to evaluate the functional outcome of supracondylar humeral fractures treated with surgery at the University Teaching Hospital of Kigali, Rwanda. Methodology: This was a combined retrospective and cross-sectional observational study. The sample size was 108. Theatre logs and OPD files were used to obtain patients' clinical information. Functional outcome was evaluated using QuickDASH score. Results: Children having 6 to 10 years of age were predominant (54.6%). Male to female ratio was 1.9:1. The left elbow was most affected (60.2%). Seventy five patients (69.4%) were within normal range, 27 (25.0%) patients had mild disability, 5 (4.7%) patients had moderate disability, and 1 (0.9%) patient had severe disability. There were no patients with very severe disability. The most common complication was elbow stiffness (59.3%), followed by gunstock deformity (27.1%). The only determinant of functional outcome found was the time (within 4 days or beyond) from injury to management (OR: 0.993, 95% CI: {0.987-1.000}, p-value: 0.048). Conclusion: For operable supracondylar humeral fractures in children, operation within 4 days and good follow up of patients in postoperative period are crucial for good functional outcome

Potential of household environmental resources and practices in eliminating residual malaria transmission: a case study of Tanzania, Burundi, Malawi and Liberia

Background: The increasing protection gaps of insecticide-treated nets and indoor-residual spraying methods against malaria have led to an emergence of residual transmission in sub-Saharan Africa and thus, supplementary strategies to control mosquitoes are urgently required. Objective: To assess household environmental resources and practices that increase or reduce malaria risk among children under-five years of age in order to identify those aspects that can be adopted to control residual transmission. Methods: Household environmental resources, practices and malaria test results were extracted from Malaria Indicators Survey datasets for Tanzania, Burundi, Malawi and Liberia with 16,747 children from 11,469 households utilised in the analysis. Logistic regressions were performed to quantify the contribution of each factor to malaria occurrence. Results: Cattle rearing reduced malaria risk between 26%-49% while rearing goats increased the risk between 26%-32%. All piped-water systems reduced malaria risk between 30%-87% (Tanzania), 48%-95% (Burundi), 67%-77% (Malawi) and 58%- 73 (Liberia). Flush toilets reduced malaria risk between 47%-96%. Protected-wells increased malaria risk between 19%-44%. Interestingly, boreholes increased malaria risk between 19%-75%. Charcoal use reduced malaria risk between 11%-49%. Conclusion: Vector control options for tackling mosquitoes were revealed based on their risk levels. These included cattle rearing, installation of piped-water systems and flush toilets as well as use of smokeless fuels

Brief report: active HIV case finding in the city of Kigali, Rwanda: assessment of voluntary assisted partner notification modalities to detect undiagnosed HIV infections

BACKGROUND: Voluntary assisted partner notification (VAPN) services that use contract, provider, or dual referral modalities may be efficient to identify individuals with undiagnosed HIV infection. We aimed to assess the relative effectiveness of VAPN modalities in identifying undiagnosed HIV infections. SETTING: VAPN was piloted in 23 health facilities in Kigali, Rwanda. METHODS: We identified individuals with a new HIV diagnosis before antiretroviral therapy initiation or individuals on antiretroviral therapy (index cases), who reported having had sexual partners with unknown HIV status, to assess the association between referral modalities and the odds of identifying HIV-positive partners using a Bayesian hierarchical logistic regression model. We adjusted our model for important factors identified through a Bayesian variable selection. RESULTS: Between October 2018 and December 2019, 6336 index cases were recruited, leading to the testing of 7690 partners. HIV positivity rate was 7.1% (546/7690). We found no association between the different referral modalities and the odds of identifying HIV-positive partners. Notified partners of male individuals (adjusted odds ratio 1.84; 95% credible interval: 1.50 to 2.28) and index cases with a new HIV diagnosis (adjusted odds ratio 1.82; 95% credible interval: 1.45 to 2.30) were more likely to be infected with HIV. CONCLUSION: All 3 VAPN modalities were comparable in identifying partners with HIV. Male individuals and newly diagnosed index cases were more likely to have partners with HIV. HIV-positive yield from index testing was higher than the national average and should be scaled up to reach the first UNAIDS-95 target by 2030

Building community and public engagement in research – the experience of early career researchers in East Africa

Background: In this paper, we explain how three early career researchers actively engaged community members in health research in Kenya, Tanzania and Uganda in their research projects, and what was learnt from the experience. The research project in Kenya was on camel trypanosomiasis and the role of camel biting keds (or louse flies) in disease transmission. The project in Tanzania looked at the effect of human immunodeficiency virus (HIV) and antiretroviral therapy on fertility and ascertained the trends in the use of family planning services amongst women of reproductive age. The focus of the project in Uganda was the implementation of maternal death surveillance and the response policy to determine the cause of maternal deaths and how they might be prevented. Methods: In the three different settings, efforts to ensure local community engagement provided a focus for the researchers to hone their skills in explaining research concepts and working in partnership with community members to co-develop ideas, their research methods and outputs. Results: Involvement of communities in scientific research, which entailed a two-way mutual engagement process, led to (i) generation of new research ideas that shaped the work, (ii) strengthened mutual trust, and (iii) promoted uptake of research findings. Conclusions: Our key findings strongly support the need for considering community engagement as one of the key components in research studies.</ns4:p

HIV incidence and prevalence among adults aged 15-64 years in Rwanda: Results from the Rwanda Population-based HIV Impact Assessment (RPHIA) and District-level Modeling, 2019

Objectives The 2018–19 Rwanda Population-based HIV Impact Assessment (RPHIA) was conducted to measure national HIV incidence and prevalence. District-level estimates were modeled to inform resources allocation. Methods RPHIA was a nationally representative cross-sectional household survey. Consenting adults were interviewed and tested for HIV using the national diagnostic algorithm followed by laboratory-based confirmation of HIV status, and testing for viral load (VL), limiting antigen (LAg) avidity and presence of antiretrovirals. Incidence was calculated using normalized optical density ≤ 1•5, VL ≥ 1,000 copies/mL, and undetectable antiretrovirals. Survey and programmatic data were used to model district-level HIV incidence and prevalence. Results Of 31,028 eligible adults, 98•7% participated in RPHIA and 934 tested HIV positive. HIV prevalence among adults in Rwanda was 3•0% (95% CI:2•7–3•3). National HIV incidence was 0•08% (95% CI:0•02–0•14) and 0•11% (95% CI:0•00–0•26) in the City of Kigali (CoK). Based on district-level modeling, HIV incidence was greatest in the three CoK districts (0•11% to 0•15%) and varied across other districts (0•03% to 0•10%). Conclusions HIV prevalence among adults in Rwanda is 3.0%; HIV incidence is low at 0.08%. District-level modeling has identified disproportionately affected urban hotspots: areas to focus resources

Establishing a library of resources to help people understand key concepts in assessing treatment claims—The “Critical thinking and Appraisal Resource Library” (CARL)

Background People are frequently confronted with untrustworthy claims about the effects of treatments. Uncritical acceptance of these claims can lead to poor, and sometimes dangerous, treatment decisions, and wasted time and money. Resources to help people learn to think critically about treatment claims are scarce, and they are widely scattered. Furthermore, very few learning-resources have been assessed to see if they improve knowledge and behavior. Objectives Our objectives were to develop the Critical thinking and Appraisal Resource Library (CARL). This library was to be in the form of a database containing learning resources for those who are responsible for encouraging critical thinking about treatment claims, and was to be made available online. We wished to include resources for groups we identified as ‘intermediaries’ of knowledge, i.e. teachers of schoolchildren, undergraduates and graduates, for example those teaching evidence-based medicine, or those communicating treatment claims to the public. In selecting resources, we wished to draw particular attention to those resources that had been formally evaluated, for example, by the creators of the resource or independent research groups. Methods CARL was populated with learning-resources identified from a variety of sources—two previously developed but unmaintained inventories; systematic reviews of learning-interventions; online and database searches; and recommendations by members of the project group and its advisors. The learning-resources in CARL were organised by ‘Key Concepts’ needed to judge the trustworthiness of treatment claims, and were made available online by the James Lind Initiative in Testing Treatments interactive (TTi) English (www.testingtreatments.org/category/learning-resources).TTi English also incorporated the database of Key Concepts and the Claim Evaluation Tools developed through the Informed Healthcare Choices (IHC) project (informedhealthchoices.org). Results We have created a database of resources called CARL, which currently contains over 500 open-access learning-resources in a variety of formats: text, audio, video, webpages, cartoons, and lesson materials. These are aimed primarily at ‘Intermediaries’, that is, ‘teachers’, ‘communicators’, ‘advisors’, ‘researchers’, as well as for independent ‘learners’. The resources included in CARL are currently accessible at www.testingtreatments.org/category/learning-resources Conclusions We hope that ready access to CARL will help to promote the critical thinking about treatment claims, needed to help improve healthcare choices

Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial

Background Early rapid fluid resuscitation (boluses) in African children with severe febrile illnesses increases the 48-hour mortality by 3.3% compared with controls (no bolus). We explored the effect of boluses on 48-hour all-cause mortality by clinical presentation at enrolment, hemodynamic changes over the first hour, and on different modes of death, according to terminal clinical events. We hypothesize that boluses may cause excess deaths from neurological or respiratory events relating to fluid overload. Methods Pre-defined presentation syndromes (PS; severe acidosis or severe shock, respiratory, neurological) and predominant terminal clinical events (cardiovascular collapse, respiratory, neurological) were described by randomized arm (bolus versus control) in 3,141 severely ill febrile children with shock enrolled in the Fluid Expansion as Supportive Therapy (FEAST) trial. Landmark analyses were used to compare early mortality in treatment groups, conditional on changes in shock and hypoxia parameters. Competing risks methods were used to estimate cumulative incidence curves and sub-hazard ratios to compare treatment groups in terms of terminal clinical events. Results Of 2,396 out of 3,141 (76%) classifiable participants, 1,647 (69%) had a severe metabolic acidosis or severe shock PS, 625 (26%) had a respiratory PS and 976 (41%) had a neurological PS, either alone or in combination. Mortality was greatest among children fulfilling criteria for all three PS (28% bolus, 21% control) and lowest for lone respiratory (2% bolus, 5% control) or neurological (3% bolus, 0% control) presentations. Excess mortality in bolus arms versus control was apparent for all three PS, including all their component features. By one hour, shock had resolved (responders) more frequently in bolus versus control groups (43% versus 32%, P <0.001), but excess mortality with boluses was evident in responders (relative risk 1.98, 95% confidence interval 0.94 to 4.17, P = 0.06) and 'non-responders' (relative risk 1.67, 95% confidence interval 1.23 to 2.28, P = 0.001), with no evidence of heterogeneity (P = 0.68). The major difference between bolus and control arms was the higher proportion of cardiogenic or shock terminal clinical events in bolus arms (n = 123; 4.6% versus 2.6%, P = 0.008) rather than respiratory (n = 61; 2.2% versus 1.3%, P = 0.09) or neurological (n = 63, 2.1% versus 1.8%, P = 0.6) terminal clinical events. Conclusions Excess mortality from boluses occurred in all subgroups of children. Contrary to expectation, cardiovascular collapse rather than fluid overload appeared to contribute most to excess deaths with rapid fluid resuscitation. These results should prompt a re-evaluation of evidence on fluid resuscitation for shock and a re-appraisal of the rate, composition and volume of resuscitation fluids. Trial registration: ISRCTN6985659

Reward and attitudes: The unintended outcomes of an effective performance appraisal

Orientation: Focus was on the role of reward and attitudes as major determinants in enhancing the effectiveness of performance appraisal systems. Research purpose: To develop a structural model from the qualitative and quantitative findings from which to address the identified gaps in order to improve the effectiveness of appraisals. Motivation for the study: The attention that role players tended to give to the rewarding of employees during the appraisal process made it appear as the only important determinant of an appraisal’s success. In appraisals in many public institutions, reward has been given unnecessary prominence over other drivers, such as management and development. That led most key role players (leaders, managers and employees) to perceive the current employee performance management and development system (EPMDS) to be purely for monetary (salary increments and cash bonuses) and non-monetary (promotion) purposes, which, in turn, compromised its effectiveness. Research design, approach and method: Structural equation modelling (SEM) was utilised as a statistical technique for testing and estimating causal relations using a combination of statistical data and qualitative causal assumptions. This allowed both confirmatory and exploratory modelling to be undertaken, which is suited to both theory testing and theory development. A triangulation of quantitative (questionnaire) and qualitative (interview) study was conducted. A total of 300 questionnaires were distributed to nine government hospitals in the Free State province, namely Mofumahadi Manapo Mopeli, Dihlabeng, and Boitumelo regional hospitals, as well as Elizabeth Ross, Thebe, Phekolong, Mpumelelo, Reitz and Ficksburg district hospitals. There was a high response rate of 96 per cent, a total of 287 completed questionnaires. Respondents ranged from top executives, middle management, line management, to employees of all categories. Main findings: Reward and attitudes were found to the unintended outcomes of an effective performance appraisal. Practical/managerial implications: Remunerative rewards should be part of a holistic appraisal approach and not simply a one-sided approach. Contribution/value-add: This article addressed the void or the wrong perception regarding the role of reward and attitudes in appraisals, and established that they were outcomes, and not determinants, of appraisal effectiveness