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

Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014

Setting: Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. Objective: To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. Design: A retrospective descriptive cohort study using routinely collected data involving adult patients aged 18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Results: Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. Conclusion: By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs

Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes

SETTING: In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care. OBJECTIVE: To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda. DESIGN: We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes. RESULTS: Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma. CONCLUSION: Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.</p

Treatment of non-communicable disease in rural resource-constrained settings: a comprehensive, integrated, nurse-led care model at public facilities in Rwanda

Background: Low-income countries face a dual burden of endemic chronic non-communicable diseases (NCDs) and limited resources to implement control strategies. Access to services is even more challenging for patients in countries like Rwanda, where more than 80% of the population reside in rural areas, and there is fewer than one health care provider per 1000 people. Many studies of NCD care delivery models in low-income countries are limited to simple conditions or focus on a single disease. Since 2007, Partners in Health/Inshuti Mu Buzima (PIH/IMB) has been supporting delivery of NCD services at Ministry of Health facilities. Here we describe the model implemented and baseline characteristics of patients served. Methods: Comprehensive NCD services are provided by nurses to patients with an array of complex conditions including heart failure, chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases on disease-specific clinic days. Nurses receive training and longitudinal mentorship from specialist physicians and use reference-standardised diagnosis and treatment protocols. Point-of-care diagnostics are used, such as haemoglobin A1c for patients with diabetes and coagulation testing for patients on warfarin after cardiac valve surgery. Nurses are also able to perform simplified echocardiography to inform initial management of heart failure. Group education sessions and socioeconomic supports are also offered to patients. District hospital nurses serve as mentors for health centre nurses. Community health workers provide support to high-risk patients. Clinical information is documented in structured forms that are compiled in individual patient charts, and entered in an electronic medical records system. These programmes are integrated within MOH facilities and most clinicians are MOH employees. Findings: At Sept 30, 2014, three district hospitals and seven health centres have implemented PIH/IMB-supported NCD programmes. 3367 patients have been enrolled, of whom 67% are female (mean age 48·1 years [SD 19·8]). Disease categories, in descending order of predominance, are: hypertension (30%), chronic respiratory disease (26%), heart failure (26%), and diabetes (16%). A small proportion (2·5%) of patients are HIV positive and 1% have more than one NCD diagnosis. More than 80% (3014) of patients live in rural districts, and of these more than 60% of those with documented occupation (683 out of total documented 1112) are subsistence farmers. Interpretation: An integrated, nurse-led NCD care model has been effectively implemented in Rwanda, providing comprehensive longitudinal care embedded within the public health system in a rural resource-constrained setting. That so many patients have been treated highlights the NCD needs in rural poor populations. Positive outcomes have been described previously for heart failure, and outcomes assessments for diabetes, post-cardiac surgery, and hypertension are underway. The experience from these facilities has contributed to ongoing scale-up of district level NCD services throughout Rwanda. Funding: Ministry of Health, Rwanda, Partners in Health /Inshuti Mu Buzima (PIH / IMB), Medtronic Foundation

Pediatric rheumatic carditis in Italy and Rwanda: The same disease, different socio-economic settings

Background: Acute Rheumatic Fever and Rheumatic Heart Disease are the leading cause of acquired heart disease in Low-Income Countries, and a common cause in High-Income Countries. We compared rheumatic carditis, its echocardiographic presentation at diagnosis and its progression in Italy and Rwanda. Methods: Retrospective study including all consecutive patients diagnosed with rheumatic carditis in an Italian (IT) and two Rwandan Hospitals (RW). Echocardiography was performed at diagnosis and three follow-up visits. Baseline characteristics, history of primary and secondary prophylaxis and cardiovascular complications data were collected. Results: Seventy-nine and 135 patients were enrolled in IT and RW, respectively. Mitral regurgitation was the most common lesion (IT: 70%, RW: 96%) in both cohorts; mixed valve lesions and severe lesions were more prevalent in RW. Age at diagnosis (IT: 8.4 ± 2.9 yrs.; RW: 11.1 ± 2.7 yrs.; P &lt; 0.001), adherence to secondary prophylaxis (IT: 99%; RW: 48%; P &lt; 0.001) and history of primary prophylaxis (IT: 65%; RW: 6%; P &lt; 0.001) were different. During the follow-up, native valve lesions completely resolved in 38% of IT and in 2% of RW patients (P &lt; 0.001). By contrast, cardiac surgery was performed in 31% of RW and 5% of IT patients (P &lt; 0.001). Cardiovascular complications and death were only observed in RW. Conclusions: The more severe cardiac involvement, the higher rate of valve surgery, CV complications and deaths in RW, could be due to delayed diagnosis and treatment, scarce adherence to secondary prophylaxis and differences in social determinants of health

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Background In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery. Methods We collected data from charts at non-communicable disease (NCD) clinics at three rural district hospitals in Rwanda to describe the outcomes of 54 patients with RHD who received cardiac valve surgery during 2007–2015. Results The majority of patients were adults (46/54; 85%), and 74% were females. The median age at the time of surgery was 22 years in adults and 11 years in children. Advanced symptoms—New York Heart Association class III or IV—were present in 83% before surgery and only 4% afterwards. The mitral valve was the most common valve requiring surgery. Valvular surgery consisted mostly of a single valve (56%) and double valve (41%). Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation. Conclusion Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery

ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries.

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite. In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT programming skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) application used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software. We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them. Further clinical validation studies are underway in Tanzania, Rwanda, Kenya, Senegal, and India

Decentralization and integration of advanced cardiac care for the world’s poorest billion through the PEN-plus strategy for severe chronic non-communicable disease

© 2024 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/ licenses/by/4.0/.Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.The PEN-Plus Cardiac Expert group is supported through grant #192269 from the American Heart Association.info:eu-repo/semantics/publishedVersio

ePOCT+ and the medAL-; suite; : development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite. In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT programming skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) application used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software. We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them. Further clinical validation studies are underway in Tanzania, Rwanda, Kenya, Senegal, and India

Rwanda 20 years on: investing in life

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery