Estimating mortality risk in burn patients admitted at Rwanda's largest referral hospital

BACKGROUND

Burns is a disease of poverty, disproportionately affecting populations in low- and middle-income countries, where most of the injuries and the deaths caused by burns occurs. In Sub-Saharan Africa, it is estimated that one fifth of burn victims die from their injuries. Mortality prediction indexes are used to estimate outcomes after provided burn care, which has been used in burn services of high-income countries over the last 60 years. It remains to be seen whether these are reliable in low-income settings. This study aimed to analyze in-hospital mortality and to apply mortality estimation indexes in burn patients admitted to the only specialized burn unit in Rwanda.

METHODS

This retrospective study included all patients with burns admitted at the burn unit (BU) of the University Teaching Hospital in Kigali (CHUK) between 2005 and 2019. Patient data were collected from the BU logbook. Descriptive statistics were calculated with frequency (%) and median (interquartile range, IQR). Association between burns characteristics and in-hospital mortality was calculated with Fisher's exact test, and Wilcoxon rank, as appropriate. Mortality estimation analysis, including Baux score, Lethal Area 50 (LA50), and point of futility, was calculated in those patients with complete data on age and TBSA. LA50 and point-of-futility were calculated using logistic regression.

RESULTS

Among the 1093 burn patients admitted at the CHUK burn unit during the study period, 49% (n=532) had complete data on age and TBSA. Their median age, TBSA, and Baux score were 3.4 years (IQR 1.9-17.1), 15% (IQR 11-25), and 24 (IQR 16-38), respectively. Overall, reported in-hospital mortality was 13% (n=121/931), LA50 for Baux score was 89.9 (95% CI 76.2-103.7), and the point-of-futility was at a Baux score of 104.

CONCLUSION

Mortality estimation indexes based on age and TBSA are feasible to use in low-income settings. However, implementation of systematic data collection would contribute to a more accurate calculation of the mortality risk.

Autologous Bone Graft From the Ipsilateral Distal Femur in Tibial Condyle Fractures

SUMMARY

Fractures of the proximal tibia often require void filling to support articular fragments in combination with internal fixation. The most common techniques are iliac autograft, allograft, or synthetic bone graft substitutes.The distal femur and its large volume condyles are a source of cancellous bone graft within the surgical site of an open reduction and internal fixation procedure. We have used a minimally invasive technique to harvest bone graft from the distal femur, using a bone graft drill. We performed this investigation to determine whether our technique of using distal femoral autograft to fill bone voids when treating proximal tibial fractures with open reduction and internal fixation is effective and safe. We also sought to determine the degree to which the bone graft incorporates into the tibia during fracture healing, the degree to which the harvest site heals, and the degree of secondary joint line depression.In all 12 patients, the bone graft had sufficient volume to fill the subchondral void in the proximal tibia, all fractures had healed at follow-up, and fracture reduction was maintained in most cases. We found no pain at the harvest site during follow-up, and there were no signs of drill penetration in articular or cortical structures. Drill holes at the harvest site showed sparse amounts of newly formed bone on CT in most of its circumference in all patients.There were no pathological changes in the femoral condyles with relation to the bone grafting procedure, and 5 patients showed radiographic signs of osteoarthritis in one or more joint compartments of the knee. The results showed this technique to provide similar success as reported alternatives without major complications and we continue to use this technique of harvesting distal femoral autograft to supplement open reduction and internal fixation of selected proximal tibial fractures.

What is the role of global health and sustainable development in Swedish medical education? A qualitative study of key stakeholders' perspectives

BACKGROUND

Global health and sustainable development have increasingly been recognised as important parts of medical education, yet education on these issues remains fragmented and scarce. In 2020, a bill to reform the national medical curricula across all Swedish medical schools was introduced, including a greater emphasis on global health and sustainable development. This study aimed to explore the perspectives of key stakeholders in medical education on the role of global health and sustainable development in Swedish medical education.

METHODS

This was a qualitative study based on semi-structured interviews with 11 key stakeholders in medical education, broadly defined as faculty board members (dean and/or vice-deans for medical education) and/or programme chairs representing six universities. Data were analysed using qualitative content analyis (QCA). The study was conducted according to the Consolidated Criteria for Reporting Qualitative research (COREQ) guidelines.

RESULTS

Stakeholders discussed the challenges and opportunities associated with the modification of medical education, which was seen as necessary modernisation to fit the changing societal perception of the role of medical doctors. The anchoring process of redesigning the curriculum and integrating global health and sustainable development was discussed, with emphasis on ownership and mandate and the role of teachers and students in the process. Finding a shared understanding of global health and sustainable development was perceived as a challenge, associated with resistance due to fear of curriculum overload. To overcome this, integrating global health and sustainable development with other topics and developing existing components of the curricula were seen as important. Additionally, it was stressed that fostering capacity building and developing infrastructure, including utilization of digital tools and collaborations, were essential to ensure successful implementation.

CONCLUSIONS

Medical institutions should prepare future doctors to respond to the needs of a globalised world, which include knowledge of global health and sustainable development. However, conceptual uncertainties and questions about ownership remain among key stakeholders in medical education. Yet, key stakeholders also highlight that the inclusion of global health and sustainable development in the new curricula represents multiple overarching educational opportunities that can bring about necessary improvement.

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda

Background

Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda.

Methods

This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis.

Results

Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%.

Conclusions

Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients’ acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.

Discrimination in an "equal country"-a survey amongst Swedish final-year medical students

BACKGROUND

Discrimination due to gender and ethnicity has been found to be widespread in medicine and healthcare. Swedish and European legislation list seven discrimination grounds (age, sex, ethnicity, religion, sexuality, non-binary gender identity, and disability) which may intersect with each other; yet these have only been sparsely researched. The aim of this study was to assess the extent of discrimination, based on these seven discrimination grounds, amongst final-year medical students in Sweden.

METHODS

A web-based survey, based on the CHERRIES-checklist, was disseminated to course coordinators and program directors in charge of final year medical students at all seven medical schools in Sweden. Quantitative data were analyzed using descriptive statistics, Fisher's exact test, and logistic regression. Free-text answers were analyzed thematically using the "Master Suppression techniques" conceptual framework.

RESULTS

Of the 1298 medical students contacted, 247 (19%) took part in the survey. Almost half (n = 103, 42%) had experienced some form of discrimination, and this difference was statistically significant by gender (p = 0.012), self-perceived ethnicity (p < 0.001), country of birth other than Scandinavia (p < 0.001) and visible religious signs (p = 0.037). The most common type of discrimination was gender-based (in 83% of students who had experienced discrimination), followed by age (48%), and ethnicity (42%). In the logistic regression, women/non-binary gender (p = 0.001, OR 2.44 [95% CI 1.41-4.22]), country of birth not in Scandinavia (p < 0.001, OR 8.05 [2.69-24.03]), non-Caucasian ethnicity (p = 0.04, OR 2.70 [1.39-5.27]), and disability (p = 0.02, OR 13.8 [1.58-12040]) were independently associated with discrimination. Half of those who had experienced religion-based discrimination and nearly one-third of victims of ethnicity-based discrimination reported "large" or "extreme" impact of this. Clinical staff or supervisors were the most common offenders (34%), closely followed by patients and their relatives (30%), with non-Caucasian respondents significantly more likely to experience discrimination by patients (p < 0.001).

CONCLUSIONS

Discrimination appears to be frequent in medical school, even in one of the world's "most equal countries". Discrimination is most commonly gender- or ethnicity-based, with ethnicity- and religion-based discrimination appearing to have the largest impact. Future research should continue to evaluate discrimination from an intersectional perspective, adapted for local contexts and legislations.

Who tells the story of burns in low-and-middle income countries? – A bibliometric study

INTRODUCTION

Low- and middle-income countries (LMICs) remain drastically underrepresented in health research, with African countries producing less than 1% of the global output. This work investigates authorship patterns of publications on burns in LMICs. Original research studies addressing burn injuries in LMICs and published between 1st January 2015 and 31st December 2020 were included in the review. Descriptive statistics were performed for country affiliations of authors, World Bank Country Income Groups, WHO group, study-focus and country studied. Of the 458 results, 426 studies met the inclusion criteria. Nearly a quarter of papers on burns in LMICs had both first and senior authors from high-income countries (HICs, n = 95, 24.4%), more than half of the papers had both first and senior authors from upper middle- income countries (upper MICs, n = 222, 57.2%), while less than 1% (n = 3) had first and senior authors exclusively from lower-income countries (LICs). Eleven percent (n = 41/388) of all papers were written without either first nor senior author being from the country studied, and 17 of them (41%) had both first and senior authors from the USA. Twenty-five (6%) of the papers had the first author and not the senior author from the country of focus, while six (2%) had the senior and not the first author from the country of interest. To overcome global health challenges such as burns, locally led research is imperative. The maximum benefit of HIC-LMIC collaborations is achieved when LMICs play an active role in leading the research. When LMICs direct the research being conducted in their country, the harm of inherently inequitable relationships is minimized.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries

BACKGROUND

The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries.

METHOD

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach.

RESULTS

Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers.

CONCLUSION

Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

Systematic media review: A novel method to assess mass-trauma epidemiology in absence of databases-A pilot-study in Rwanda

Objective

Surge capacity refers to preparedness of health systems to face sudden patient inflows, such as mass-casualty incidents (MCI). To strengthen surge capacity, it is essential to understand MCI epidemiology, which is poorly studied in low- and middle-income countries lacking trauma databases. We propose a novel approach, the “systematic media review”, to analyze mass-trauma epidemiology; here piloted in Rwanda.

Methods

A systematic media review of non-academic publications of MCIs in Rwanda between January 1^st, 2010, and September 1^st, 2020 was conducted using NexisUni, an academic database for news, business, and legal sources previously used in sociolegal research. All articles identified by the search strategy were screened using eligibility criteria. Data were extracted in a RedCap form and analyzed using descriptive statistics.

Findings

Of 3187 articles identified, 247 met inclusion criteria. In total, 117 MCIs were described, of which 73 (62.4%) were road-traffic accidents, 23 (19.7%) natural hazards, 20 (17.1%) acts of violence/terrorism, and 1 (0.09%) boat collision. Of Rwanda’s 30 Districts, 29 were affected by mass-trauma, with the rural Western province most frequently affected. Road-traffic accidents was the leading MCI until 2017 when natural hazards became most common. The median number of injured persons per event was 11 (IQR 5–18), and median on-site deaths was 2 (IQR 1–6); with natural hazards having the highest median deaths (6 [IQR 2–18]).

Conclusion

In Rwanda, MCIs have decreased, although landslides/floods are increasing, preventing a decrease in trauma-related mortality. By training journalists in “mass-casualty reporting”, the potential of the “systematic media review” could be further enhanced, as a way to collect MCI data in settings without databases.

Recording Patient Data in Burn Unit Logbooks in Rwanda: Who and What Are We Missing?

Systematic data collection in high-income countries has demonstrated a decreasing burn morbidity and mortality, whereas lack of data from low- and middle-income countries hinders a global overview of burn epidemiology. In low- and middle-income countries, dedicated burn registries are few. Instead, burn data are often recorded in logbooks or as one variable in trauma registries, where incomplete or inconsistently recorded information is a known challenge. The University Teaching Hospital of Kigali hosts the only dedicated burn unit in Rwanda and has collected data on patients admitted for acute burn care in logbooks since 2005. This study aimed to assess the data registered between January 2005 and December 2019, to evaluate the extent of missing data, and to identify possible factors associated with “missingness.” All data were analyzed using descriptive statistics, Fisher’s exact test, and Wilcoxon Rank Sum test. In this study, 1093 acute burn patients were included and 64.2% of them had incomplete data. Data completeness improved significantly over time. The most commonly missing variables were whether the patient was referred from another facility and information regarding whether any surgical intervention was performed. Missing data on burn mechanism, burn degree, and surgical treatment were associated with in-hospital mortality. In conclusion, missing data is frequent for acute burn patients in Rwanda, although improvements have been seen over time. As Rwanda and other low- and middle-income countries strive to improve burn care, ensuring data completeness will be essential for the ability to accurately assess the quality of care, and hence improve it.

Exploring factors associated with research involvement of undergraduate students at the College of Medicine and Health Sciences, University of Rwanda

BACKGROUND

Early involvement of students in research processes is an important step in professional development and can increase the academic output of the university. Previous studies indicate low research involvement amongst undergraduate students, however limited research has been done in sub-Saharan Africa. This study aimed to describe the level of research involvement amongst undergraduate students at the College of Medicine and Health Sciences (CMHS) at University of Rwanda (UR) and to assess factors associated with research involvement.

METHODS

This cross-sectional study covered the three CMHS campuses. A survey was shared in class WhatsApp groups from July to September 2020. Data were analyzed using Stata IC 16.0 with descriptive statistics and Fisher's exact test. P-values < 0.05 were considered statistically significant.

RESULTS

In total, 324 students participated with the mean age being 23.3 (standard deviation 2.27). Males constituted 65.1% of respondents vs. 33.3% females. The largest portion of respondents were from the School of Medicine and Pharmacy (46.6%), and Medicine was the most frequent department (33.3%). On a Likert scale from 1 to 10, 60.0% of the respondents thought that research was 10/10 important for undergraduate students, with the mean value being 8.8. Rating their interest in taking part in research during undergraduate studies, 48.2% scored it 10/10, with the mean value being 8.57. 80.3% of respondents had attended a research module, course, or workshop; however, only 48.8% had participated in a research project and 72.0% of them had been involved in data collection. Inadequate knowledge about research processes and lack of mentors were the main barriers to research participation in 48.0 and 40.2% of respondents respectively. Establishment of a UR-Undergraduate research support center (77.2%), and involving students in ongoing UR projects (69.4%) were the most frequent suggestions to improve students' research participation.

CONCLUSION

Undergraduate students at the CMHS in the UR have a large research interest, yet their involvement is currently low. Limited knowledge about research processes and shortage of mentors remains potent barriers to participation. Inviting undergraduate students to partake in ongoing projects and establishing a UR undergraduate research support center are recommended to strengthen undergraduate research experience at the UR-CMHS.

Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences

INTRODUCTION

Global health conferences are important platforms for knowledge exchange, decision-making and personal and professional growth for attendees. Neocolonial patterns in global health at large and recent opinion reports indicate that stakeholders from low- and middle-income countries (LMICs) may be under-represented at such conferences. This study aims to describe the factors that impact LMIC representation at global health conferences.

METHODS

A systematic review of articles reporting factors determining global health conference attendance was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles presenting conference demographics and data on the barriers and/or facilitators to attendance were included. Articles were screened at title and abstract level by four independent reviewers. Eligible articles were read in full text, analysed and evaluated with a risk of bias assessment.

RESULTS

Among 8765 articles screened, 46 articles met inclusion criteria. Thematic analysis yielded two themes: 'barriers to conference attendance' and 'facilitators to conference attendance'. In total, 112 conferences with 254 601 attendees were described, of which 4% of the conferences were hosted in low-income countries. Of the 98 302 conference attendees, for whom affiliation was disclosed, 38 167 (39%) were from LMICs.

CONCLUSION

'Conference inequity' is common in global health, with LMIC attendees under-represented at global health conferences. LMIC attendance is limited by systemic barriers including high travel costs, visa restrictions and lower acceptance rates for research presentations. This may be mitigated by relocating conferences to visa-friendly countries, providing travel scholarships and developing mentorship programmes to enable LMIC researchers to participate in global conferences.

Climate change: challenges and opportunities to scale up surgical, obstetric, and anaesthesia care globally

Climate change affects human health in a myriad of ways, requiring reassessment of the nature of scaling up care delivery and the effect that care delivery has on the environment. 5 billion people do not have access to safe and timely surgical care, and the quantity and severity of conditions that require surgical, obstetric, and anaesthesia care will increase substantially as a result of climate change. However, surgery is resource intensive and contributes substantially to greenhouse-gas emissions. In response to climate change, the surgical, obstetric, and anaesthesia community has a key role to play to ensure that a scale-up of service delivery incorporates mitigation and adaptation strategies. As countries scale up surgical care, understanding the implications of surgery on climate change and the implications of climate change on surgical care will be crucial in the development of health policies.