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.

Exploring Perceptions and Acceptance of Minimally Invasive Tissue Sampling among Bereaved Relatives and Health-Care Professionals in Rwanda

Purpose

In most low- and lower middle-income countries (LMICs), minimally invasive tissue sampling (MITS) is a relatively new procedure for identifying the cause of death (CoD). This study aimed to explore perceptions and acceptance of bereaved families and health-care professionals regarding MITS in the context of MITS initiation in Rwanda as an alternative to clinical autopsy.

Methods

This was a qualitative phenomenological study with thematic analysis. Participants were bereaved relatives (individual interviews) and health-care professionals (focus-group discussions) involved in MITS implementation. It was conducted in the largest referral and teaching hospital in Rwanda.

Results

Motivators of MITS acceptance included eagerness to know the CoD, noninvasiveness of MITS, trust in medics, and the fact that it was free. Barriers to consent to MITS included inadequate explanations from health-care professionals, high socioeconomic status, lack of power to make decisions, and lack of trust in medics. Health-care professionals perceived both conventional autopsy and MITS as gold-standard procedures in CoD determination. They recommended including MITS among hospital services and commended the post-MITS multidisciplinary discussion panel in CoD determination. They pointed out that there might be reticence in approaching bereaved relatives to obtain consent for MITS. Both groups of participants highlighted the issue of delay in releasing MITS results.

Conclusion

Both health-care professionals and bereaved relatives appreciate that MITS is an acceptable procedure to include in routine hospital services. Dealing with barriers met by either group is to be considered in the eventual next phases of MITS implementation in Rwanda and similar sociocultural contexts.

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.

Obstructive uropathy as initial presentation of genitourinary tuberculosis and masquerading as a postsurgical complication

A 46-year-old woman who had a recent total abdominal hysterectomy presented with a 1 month history of lower abdominal pain, 1 week of nausea and vomiting as well as decreased urinary output preceded by a year of significant unintentional weight loss. On renal imaging, she was found to have bilateral hydronephrosis and hydroureters in the setting of bilateral distal ureteric obstruction complicated with acute kidney injury and severe hyperkalaemia requiring haemodialysis. The initial concern was for ureteric injury, a known complication of abdominal hysterectomy procedures, however, a urological intervention, performed 9 months later to relieve the ureteric obstruction, revealed purulent material within the left ureter that was smear positive for acid fast bacilli. A GeneXpert test was positive for Mycobacterium tuberculosis She was diagnosed with genitourinary tuberculosis and responded well to antitubercular treatment and haemodialysis was discontinued after the surgery relieved her ureteric obstruction.

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.

Safety and efficacy of the PrePex device for rapid scale-up of male circumcision for HIV prevention in resource-limited settings

OBJECTIVE

To assess the safety and efficacy of the PrePex device for nonsurgical circumcision in adult males as part of a comprehensive HIV prevention program in Rwanda.

METHODS

Single-center 6-week noncontrolled study in which healthy men underwent circumcision using the PrePex device, which employs fitted rings to clamp the foreskin, leading to distal necrosis. In the first phase of the study, the feasibility of the procedure was tested on 5 subjects in a sterile environment; in the main phase, an additional 50 subjects were circumcised in a nonsterile setting by physicians or a nurse. Outcome measures included the rate of successful circumcision, time to complete healing, pain, and adverse events.

RESULTS

In the feasibility phase, all 5 subjects achieved complete circumcision without adverse events. In the main phase, all 50 subjects achieved circumcision with 1 case of diffuse edema after device removal, which resolved with minimal intervention. Pain was minimal except briefly during device removal (day 7 after placement in most cases). The entire procedure was bloodless, requiring no anesthesia, no suturing, and no sterile settings. Subjects had no sick/absent days associated with the procedure. Median time for complete healing was 21 days after device removal. There were no instances of erroneous placement and no mechanical problems with the device.

CONCLUSION

The PrePex device was safe and effective for nonsurgical adult male circumcision without anesthesia or sterile settings and may be useful in mass circumcision programs to reduce the risk of HIV infection, particularly in resource-limited settings.

[Cryptococcosis in Burundi in 1985. Report of 30 cases]

Over a period of 23 months, 30 cases of cryptococcosis have been studied in Bujumbura (Burundi). Through them, epidemiological and clinical aspects have been underlined, and attempts have been made to establish links between cryptococcosis and A.I.D.S., which is significantly frequent in Central Africa. Cryptococcosis strikes young adults (40% between 30 and 35 years of age). Its high frequency in Bujumbura among patients infested by A.I.D.S., suggest some thoughts. A.I.D.S. in Central Africa, and particularly in Burundi, presents some peculiarities linked to surrounding and possibilities of diagnosis: opportunistic diseases are of different frequency in temperate or tropical climates: pneumocystosis are more frequent in U.S.A. but cryptococcosis and candidosis are more frequent in Africa because their diagnosis is easier. lack of classical risk factors in African populations is known, but other risk factors have to be taken into consideration: tuberculosis, intestinal parasitosis, chronic virus B hepatitis, protein-caloric deficiency.