Predictors of delayed consultation in undescended testis patients at a Rwandan referral hospital

INTRODUCTION: Delayed management of undescended testes (UDT) is associated with an increased risk of malignancy and impaired fertility. To identify causes of delayed consultation of patients with UDT at a Rwandan referral hospitalMETHODS: This was a retrospective study of patients with delayed UDT presentations from 2012 to 2016. A delayed UDT presentation was defined as any patient presenting with UDT at >1 year of age. RESULTS: There were 44 cases of delayed UDT presentations. Most patients (n = 35, 79.5%) were born at a hospital; the rest (n = 9, 20.5%) were born at home. The patient’s parent with higher education in the family was considered. Most of the patients’ parents (n = 29, 65.9%) had a primary education, 6 (13.6%) had a secondary education (high school graduate), 1 (2.3%) had a university education, and 8 (18.2%) never went to school. The reported reasons for delays as they appear in the patient chart were 16 (36.4%) patients due to ignorance, 12 (27.3%) due to poor physical examination at birth, 7 (15.9%) due to poor guidance, 4 (9.0%) due to poverty and 5 (11.4%) due to long appointments. There were no overlapping reasons for delay reported. Patients born at home were more likely to identify ignorance as a reason for the delay (p = 0.007). Of the 16 patients who reported a delay due to ignorance, 12 of their parents had primary education, and 3 had no education. Most (n = 34, 77.3%) patients were fertile in adulthood, but 9 (20.4%) presented with infertility and 1 (2.3%) presented with testicular torsion. CONCLUSION: A number of reasons are responsible for delayed consultation in patients with UDT, including ignorance, poor physical examination, poor guidance, and poverty. Most of the causes are preventable. The urgent need for awareness of UDT and collaboration between physicians is paramount for early consult and management.

Diagnosis of advanced prostate cancer at the community level in Rwanda

BACKGROUND

Prostate cancer is the second most common cancer in men and sixth leading cause of mortality. If not recognized early, patients with advanced prostate cancer can experience debilitating complications which can otherwise be prevented by early androgen deprivation therapy. This research intends to define clear diagnostic tools that will guide practitioners in the rural community setting toward early management of advanced prostate cancer.

METHODS

We conducted a cross-sectional observational study at three referral hospitals in Kigali, Rwanda on patients who presented with clinical suspicion of advanced prostate cancer over a period of 6 months. All patients underwent prostate biopsy as well as metastatic work up (CT or MRI), for those who were eligible. Statistical analysis was done using STATA 14.2.

RESULTS

114 patients were included in the study. The median age was 70 years (interquartile range: 65-79 years). In total 14 (12.3%) patients were found to have benign disease, while 100 (87.7%) patients were found to have cancer. Among those who had cancer, 85 (85%) had advanced prostate cancer. 110/114 (96.5%) were symptomatic at presentation. Common presenting symptoms were lower urinary tract symptoms (80.7%), back pain (54.4%), and urinary retention (36.8%). Abnormal digital rectal examination (DRE) was a strong risk factor for both cancer and advanced disease. Prostate cancer was found in 92.2% of those with abnormal DRE compared to 41.7% in those with normal DRE (p = 0.001). Also, cancer was found in 96.1% of those with multinodular prostate on DRE (p = 0.02) and had high odds (OR 14.6; CI 3.41-62.25) of having advanced prostate cancer (p < 0.001). The mean (± SD) PSA was 643.3 ± 1829.8 ng/ml and the median (range) was 100 ng/ml (9.05-10,000 ng/ml) for the whole study population. All patients with prostatic-specific antigen (PSA) of 100 ng/ml or above had advanced prostate cancer.

CONCLUSION

The results show that there is a significant correlation between clinical findings and advanced prostate cancer. All patients with abnormal DRE and PSA above 100 ng/ml had advanced prostate cancer. Diagnosis of advanced prostate cancer is possible at the community level if PSA testing is utilized and practitioners are well trained.

Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

Background

Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda.

Methods

This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes.

Results

In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15–60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died.

Conclusion

While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.