Perspectives on the state of cleft lip and cleft palate patient care in Africa.

PURPOSE OF REVIEW: As the most common congenital craniofacial defect, patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa. RECENT FINDINGS: To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources. SUMMARY: The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

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.

An Assessment of the Knowledge and Perceptions of Precision Medicine (PM) in the Rwandan Healthcare Setting.

INTRODUCTION: Precision medicine (PM) or personalized medicine is an innovative approach that aims to tailor disease prevention and treatment to consider the differences in people's genes, environments, and lifestyles. Although many efforts have been made to accelerate the universal adoption of PM, several challenges need to be addressed in order to advance PM in Africa. Therefore, our study aimed to establish baseline data on the knowledge and perceptions of the implementation of PM in the Rwandan healthcare setting. METHOD: A descriptive qualitative study was conducted in five hospitals offering diagnostics and oncology services to cancer patients in Rwanda. To understand the existing policies regarding PM implementation in the country, two additional institutions were surveyed: the Ministry of Health (MOH), which creates and sets policies for the overall vision of the health sector, and the Rwanda Biomedical Center (RBC), which coordinates the implementation of health sector policies in the country. The researchers conducted 32 key informant interviews and assessed the functionality of available PM equipment in the 5 selected health facilities. The data were thematically categorized and analyzed. RESULTS: The study revealed that PM is perceived as a complex and expensive program by most health managers and health providers. The most cited challenges to implementing PM included the following: the lack of policies and guidelines; the lack of supportive infrastructures and limited suppliers of required equipment and laboratory consumables; financial constraints; cultural, behavioral, and religious beliefs; and limited trained, motivated, and specialized healthcare providers. Regarding access to health services for cancer treatment, patients with health insurance pay 10% of their medical costs, which is still too expensive for Rwandans. CONCLUSION: The study participants highlighted the importance of PM to enhance healthcare delivery if the identified barriers are addressed. For instance, Rwandan health sector leadership might consider the creation of specialized oncology centers in all or some referral hospitals with all the necessary genomic equipment and trained staff to serve the needs of the country and implement a PM program.

Building Sustainable Reconstructive Microsurgery in Countries with Limited Resources: The Rwandan Experience.

Background: Reconstructive microsurgery practice has been well adopted in developed countries, but this has not been the same in low- and middle-income countries (LMICs). Injuries related to road traffic accidents are highest in these countries, with 93% of the world's fatalities on the roads occurring in LMICs. The objective of this study was to highlight the need for sustainable microsurgery in LMICs and share strategies undertaken in Rwanda. Methods: We review the contemporary literature about the needs and challenges facing reconstructive microsurgery in LMICs. We describe the strategies undertaken in Rwanda towards developing microsurgery. We also report the outcomes of the first ever microsurgery visiting professorship organized in the country and the steps taken towards achieving sustainable microsurgery practice in Rwanda. Results: There is a huge unmet need for reconstructive microsurgery in LMICs. Most of the microsurgical operations in these countries are done in short term surgical mission setups. No data focusing on sustaining reconstructive microsurgery in LMICs has been described in the contemporary literature. There is a 2.5-fold increase in the number of trained plastic surgeons in Rwanda over the past 5 years, with increasing skills in microsurgery and opportunities for formal overseas fellowships. Conclusion: With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable microsurgery services is possible in countries with limited resources. In our experience, the fly-in-fly-out microsurgical missions aimed at mainly providing surgical care to patients seem to have a limited long-term impact and sustainability. We recommend integrating these missions into planned microsurgical initiatives of pre-existing local plastic surgery training programs.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference.

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

National Surgical Healthcare Policy Development and Implementation: Where do We Stand in Africa?

BACKGROUND: National surgical policies have been increasingly adopted by African countries over the past decade. This report is intended to provide an overview of the current state of adoption of national surgical healthcare policies in Africa, and to draw a variety of lessons from representative surgical plans in order to support transnational learning. METHODS: Through a desk review of available African national surgical healthcare plans and written contributions from a committee comprising six African surgical policy development experts, a few key lessons from five healthcare plans were outlined and iteratively reviewed. RESULTS: The current state of national surgical healthcare policies across Africa was visually mapped, and lessons from a few compelling examples are highlighted. These include the power of initiative from Senegal; regional leadership from Zambia; contextualization, and renewal of commitment from Ethiopia; multidisciplinary focus and creation of multiple implementation entry points from Nigeria; partnerships and involvement of multiple stakeholders from Rwanda; and the challenge of surgical policy financing from Tanzania. The availability of global expertise, the power of global partnerships, and the critical role of health ministries and Ministers of Health in planning and implementation have also been highlighted. CONCLUSIONS: Strategic planning for surgical healthcare improvement is at various stages across the continent, with potential for countries to learn from one another. Convenings of stakeholders and Ministers of Health from countries at various stages of strategic surgical plan development, execution, and evaluation can enhance African surgical policy development through the exchange of ideas, lessons, and experiences.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review.

Purpose of Review: Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings: A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager's four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public-private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary: Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information: The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study.

INTRODUCTION: The management of severe burns and pediatric burns requires an organized system of care delivery, which includes referral guidelines. In Rwanda, the burn unit at the University Teaching Hospital of Kigali (CHUK) is the only dedicated burn unit in the country and admits patients of all ages referred from the other provinces. However, since there are no official referral guidelines, it is unknown whether patients with burns are appropriately referred. This study aims to analyze referral patterns among burn patients admitted at the CHUK burn unit and their adherence to the referral criteria listed by the American Burn Association (ABA), comparing patients transferred to the burn unit from facilities within Kigali and those referred from facilities outside Kigali. METHODS: This retrospective study included all patients with acute burns admitted to the CHUK burn unit with data available on the province of origin from 2005 to 2019. Patients with burns younger than 16 y were defined as pediatric burns, as per the CHUK routines. Characteristics of all burns referred from a facility within Kigali (Pat-K) and facilities outside Kigali (Pat-O) were compared using Fisher's exact test for categorical variables or Wilcoxon rank-sum test for continuous variables. The adherence to ABA referral criteria was assessed for variables with available data, which were total burnt surface area %, burn thickness, cause of burn, and age. RESULTS: The study population consisted of 1093 patients, of which 1064 had data regarding if they were referred from other facilities to CHUK. Overall, the median age was 3 y (2-16 y), with Pat-O being older than Pat-K (P < 0.001). Scalds were the dominant cause of injury in both groups; flame was more common among Pat-O than among Pat-K (in 25.5% versus 10.6%, P < 0.01). Burns of larger size and depth were more common among Pat-O, as compared to the Pat-K group [median total burnt surface area % = 19% versus 15.5%, respectively (P < 0.001); presence of full-thickness burns = 55.6% versus 29.7 %, respectively (P < 0.001)]. Hospitalization was longer and in-hospital mortality higher in Pat-O than in Pat-K [LOS = 42 d (interquartile range 11-164) versus 28 d (interquartile range 9-132), P < 0.05; in-hospital mortality = 18.9% versus 10.1%, P < 0.001]. Among Pat-O, 85% had characteristics that mirrored one or more of the analyzed ABA criteria. CONCLUSIONS: Although there are no clear guidelines, referral patterns indicate that patients are being appropriately referred for specialized burn care in Rwanda. Compared to patients from Kigali, rural patients had larger and more severe injuries, needed more surgical interventions, and had worse outcomes. Most of referred patients matched criteria listed among international referral guidelines. However, the statement of national referral criteria is essential to improve timely access to adequate care.

Unusual anatomical variations of the hepatic arteries and bile ducts: What are the surgical implications.

Introduction: The knowledge of anatomy is essential for surgical safety and impacts positively on patients' outcomes. Surgeons operating on the liver and bile ducts should keep in mind the normal anatomy and its variations as the latter are common. Case Presentation: We conducted a structured surgical dissection course of the supra-colic compartment of the abdominal cavity on 2nd and 3rd October 2020. While dissecting a 46years-old male cadaver, we encountered unusual anatomical variations of the hepatic arterial branching, the biliary tree, and arterial supply to the common bile duct. The common hepatic artery was dividing into two branches: a common short trunk for the left hepatic artery and the right gastric artery (hepato-gastric trunk) and a common trunk for the right hepatic artery and gastroduodenal artery (hepato-gastroduodenal trunk). The right hepatic duct was duplicated with a main right hepatic duct and an additional smaller duct. The bile duct was supplied by an artery coming from the abdominal aorta. Conclusion: We described three unusual anatomical variations: a variation of the hepatic arteries branching pattern, an aberrant right hepatic duct, and blood supply to the bile duct from the abdominal aorta. Surgeons should be aware of these rare variations.

Building Trauma and EMS Systems Capacity in Rwanda: Lessons and Recommendations.

Background: Surgical capacity building has gained substantial momentum. However, care at the hospital level depends on improved access to emergency services. There is no established model for facilitating trauma and EMS system capacity in LMIC settings. This manuscript describes our model for multi-disciplinary collaboration to advance trauma and EMS capacity in Rwanda, along with our lessons and recommendations. Methods: After high-level meetings at the Ministry of Health in Rwanda (MOH), in 2016, a capacity building plan focusing on improved clinical services, quality improvement/research and leadership capacity across prehospital and emergency settings. The main themes for the collaborative model included for empowerment of staff, improving clinical service delivery, and investing in systems and infrastructure. Funding was sought and incorporated into the Sector Wide Approaches to Planning process at the Ministry of Health of Rwanda. Findings: A shared mental model was created through a fully funded immersion program for Rwandese leaders from emergency medicine, nursing, prehospital care, and injury policy. Prehospital care delivery was standardized within Kigali through a train-the-trainers program with four new context-appropriate short courses in trauma, medical, obstetric/neonatal, and pediatric emergencies and expanded across the country to reach >600 staff at district and provincial hospitals. Forty-two protocols and checklists were implemented to standardize prehospital care across specialties. The WHO Trauma Registry was instituted across four major referral centers in the country capturing over 5,000 injured patients. Long-term research capacity development included Masters' Degree support for 11 staff. Conclusions and Recommendations: This collaboration was highly productive in empowering staff and leadership, standardizing clinical service delivery in EMS, and investing in systems and infrastructure. This can be a useful model for trauma and EMS system capacity development in other LMICs.

Premenopausal Breast Cancer Risk Factors and Associations with Molecular Subtypes: A Case-Control Study.

BACKGROUND: Breast cancer (BC) is the most prevalent cancer in women and the leading cause of women's cancer-related deaths and morbidity worldwide. In Rwanda, BC incidence is increasing with an unacceptably high mortality rate in premenopausal women. OBJECTIVES: The purpose was to identify modifiable BC risk factors and assess associations between common breast cancer risks factors and molecular subtypes in premenopausal women in Rwanda. METHODS: This was a case-control study. Premenopausal women with histological confirmation of BC and frequency-matched for age controls were recruited. A preestablished questionnaire was administered to both cases and controls for sociodemographics, BC probable risk factors, and clinical and pathological characteristics. BC was classified into luminal A, luminal B, HER2-type, basal-like (triple negative), and unclassified molecular subtypes by immunohistochemistry (IHC). Odds ratio (OR) and 95% confidence interval (CI) were estimated using multivariate logistic regression analysis. RESULTS: 340 participants were recruited into the study (170 cases vs. 170 controls). The median age was 39 years. The majority of cases presented at advanced stages of the disease (51.2% in stages III and IV) and had invasive ductal carcinoma (98.2%). 60.6% had subtypes of poor prognosis (HER2 enriched 14.7%, triple negative 12.9%, and unclassified 32.9%). Alcohol intake (AOR = 3.73, 95%CI 2.19 - 6.32, p < 0.001), obesity/overweight in adolescence or early adulthood (AOR = 10.86, 95%CI 4.82 - 24.4, p < 0.001), history of primary infertility (AOR = 33.8, 95%CI 3.5 - 321.5, p = 0.002), nulliparity (AOR = 3.75, 95%CI 1.61 - 8.75, p = 0.002), and a history of benign breast disease (AOR = 6.06, 95%CI 1.19 - 30.73, p = 0.03) were associated with the occurrence of premenopausal breast cancer. There was no significant difference between risk factor stratification per molecular subtype. CONCLUSION: Several reproductive, environmental, and lifestyle risk factors have been identified to be associated with premenopausal BC. Among them, alcohol intake and obesity/overweight during adolescence/early adulthood can be modified. Interventions targeting alcohol consumption and obesity/overweight in adolescents and young adults may decrease the incidence of premenopausal breast cancer.

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 1st, 2010, and September 1st, 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.

What is Known About Burns in East Africa? A Scoping Review.

BACKGROUND: Burns are a global public health concern, with the majority of the disease burden affecting low- and middle-income countries. Yet, as suggested by previous publications, there is a widespread belief that literature about burns in low- and middle-income countries is lacking. Therefore, we aimed to assess with a scoping review, the extent of the literature output on burns in East Africa, and to investigate patient demographics, injury characteristics, treatment and outcomes, as reported from the existing publications. METHODS: Studies discussing burns in East Africa were identified by searching PubMed / Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO), and Global Index Medicus on December 12, 2019. Controlled vocabulary terms (i.e., MeSH, EMTREE, Global Health thesaurus terms) were included when available and appropriate. No year restrictions were applied. RESULTS: A total of 1,044 records were retrieved from the database searches, from which 40 articles from 6 countries published between 1993 and 2019 were included in the final review. No studies were found from five East African countries with the lowest GDP. Most papers focused on pediatric trauma patients or tertiary hospital settings. The total number of burn patients recorded was 44,369, of which the mean proportion of males was 56%. The most common cause of injury was scalds (61%), followed by open flame (17%). Mortality rate ranged from 0-67%. The mean length of stay in hospital was between 9-60 d. CONCLUSIONS: Burn data is limited in the East African region, with socio-economically weak countries being particularly underrepresented. This scoping review has identified the largest set of literature on burns in East Africa to date, indicating the importance of reviewing data at a regional or local level, as "global" studies tend to be dominated by high-income country data. Data collection in specific registries is needed to better characterize the exact burden of burn injuries in East Africa.

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.

Use of Student-Generated Multiple Choice Questions to Enhance Team-Based Learning of Anatomy at the University of Rwanda.

INTRODUCTION: Teaching of human anatomy has undergone significant changes in the past three decades. At the University of Rwanda, anatomy is being taught using team-based learning (TBL). While student-generated multiple choice questions (MCQs) stimulate deeper thinking on a given topic, their impact on anatomy learning is not known. This study aimed to find out the impact of student-generated MCQs on the current anatomy teaching method at the University of Rwanda. METHODS: In this comparative interventional study, two similar chapters on anatomy were selected; one was taught using TBL while for the other one, in addition to TBL, students were encouraged to set MCQs while studying. Pre- and post-test scores were analyzed using SPSS 23 and the Student's t-test was used to compare the mean scores obtained. RESULTS: Thirty-one medical students were recruited. Pre-test mean scores were 25.10 and 25.19 out of 50 for chapters 1 and 2, respectively. Although the students' post-test scores improved after teaching for each chapter, the improvement was much greater for chapter 2 than for chapter 1, with mean scores of 39.97 and 32.45 out of 50, respectively (P<0.05). Despite such improvement, almost half of the students found that setting MCQs was not easy. CONCLUSION: This study found that student-generated MCQs can be used as a simple and cost-effective tool to enhance TBL of anatomy.

State of Cancer Control in Rwanda: Past, Present, and Future Opportunities.

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country's 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.

A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda.

OBJECTIVE: Breast cancer incidence is rising for women in low and middle income country (LMIC)s. Growing the health care workforce trained in clinical breast exam (CBE) is critical to mitigating breast cancer globally. We developed a CBE simulation training course and determined whether training on a low-fidelity (LF) simulation model results in similar skill acquisition as training on high-fidelity (HF) models in Rwanda. DESIGN: A single-center randomized educational crossover trial was implemented. A preintervention baseline exam (exam 1), followed by a lecture series (exam 2), and training sessions with assigned simulation models was implemented (exam 3)-participants then crossed over to their unassigned model (exam 4). The primary outcome of this study determined mean difference in CBE exam scores between HF and LF groups. Secondary outcomes identified any provider level traits and changes in overall scores. SETTING: The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from July 2014 to March 2015 PARTICIPANTS: Medical students, residents in surgery, obstetrics and gynecology, and internal medicine residents participated in a 1-day CBE simulation training course. RESULTS: A total of 107 individuals were analyzed in each arm of the study. Mean difference in exam scores between HF and LF models in exam 1 to 4 was not significantly different (exam 1 0.08 standard error (SE) = 0.47, p = 0.42; exam 2 0.86, SE = 0.69, p = 0.16; exam 3 0.03, SE = 0.38, p = 0.66; exam 4 0.10 SE = 0.37, p = 0.29). Overall exam scores improved from pre- to post-intervention. CONCLUSIONS: Mean difference in exams scores were not significantly different between participants trained with HF versus LF models. LF models can be utilized as cost effective teaching tools for CBE skill acquisition, in resource poor areas.