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Rubagumya F, Wilson B, Manirakiza A, Mutabazi E, A. Ndoli D, Rudakemwa E, Chamberlin MD, Hopman WM, Booth CM. Financial Toxicity: Unveiling the Burden of Cancer Care on Patients in Rwanda. Oncologist 2024; 29:e345-e350. [PMID: 37897406 PMCID: PMC10911921 DOI: 10.1093/oncolo/oyad291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/05/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. METHODS This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. RESULTS 239 patients were included; 75% (n = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n = 106/239) of respondents sold property, 29% (n = 70/239) asked for charity from public, family, or friends, and 16% (n = 37/239) took loans with interest to fund cancer treatment. CONCLUSION Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care.
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Affiliation(s)
- Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda
- Department of Oncology, Research for Development (RD), Gasabo, Kigali, Rwanda
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Departments of Oncology, Queen’s University, Kingston, Ontario, Canada
- Department of Oncology, Dartmouth Cancer Center, Lebanon, NH, USA
| | - Brooke Wilson
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Departments of Oncology, Queen’s University, Kingston, Ontario, Canada
- University of Sydney, School of Public Health, Sydney, NSW, Australia
| | - Achille Manirakiza
- Oncology Unit, Department of Medicine, King Faisal Hospital, Gasabo, Kigali, Rwanda
| | - Emmanuel Mutabazi
- Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda
| | - Diane A. Ndoli
- Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda
| | - Emmanuel Rudakemwa
- Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda
| | | | - Wilma M Hopman
- Department of Oncology, Kingston Health Sciences, Kingston, Ontario, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Departments of Oncology, Queen’s University, Kingston, Ontario, Canada
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Kachapila M, Oppong R, Ademuyiwa AO, Bhangu A, Dauda R, Ghosh DN, Kamarajah SK, Lawani I, Medina ARDL, Monahan M, Morton DG, Omar O, Picciochi M, Tabiri S, Roberts TE, Brocklehurst P, Chakrabortee S, Glasbey J, Hardy P, Harrison E, Lillywhite R, Magill L, Nepogodiev D, Simoes J, Smith D, Kadir B, Pinkney T, Brant F, Li E, Runigamugabo E, Bahrami-Hessari M, Bywater E, Martinez L, Habumuremyi S, Ntirenganya F, Williams E, Fourtounas M, Melic BKC, Ghosh DN, Suroy A, Ahogni D, Ahounou A, Boukari KA, Gbehade O, Hessou TK, Nindopa S, Nontonwanou MB, Guessou NO, Sambo A, Tchati SV, Tchogo A, Tobome SR, Yanto P, Gandaho I, Hadonou A, Hinvo S, Hodonou MA, Tamou SB, Lawani S, Dossou FM, Gaou A, Goudou R, Kouroumta MC, Lawani I, Malade E, Dikao ASM, Nsilu JN, Ogouyemi P, Akpla M, Mitima NB, Kovohouande B, Loupeda SL, Agbangla MV, Hedefoun SE, Mavoha T, Ngaguene J, Rugendabanga J, Soton RR, Totin M, Agbadebo M, Dewamon H, Akpo I, Djeto M, Hada A, Hollo M, Houndji A, Houndote A, Hounsa S, Kpatchassou E, Yome H, Alidou MM, Bara EJ, Yovo BBD, Guinnou R, Hamadou S, Kola H, Moussa N, Cakpo B, Etchisse L, Hatangimana E, Muhindo M, Sanni K, Yevide AB, Agossou H, Musengo FB, Behanzin H, Seto DM, Alia BA, Alitonou A, Mehounou Y, Agbanda L, Attinon J, Hounsou NR, Gbassi M, Adagrah A, Alhassan BBA, Amoako-Boateng MP, Appiah AB, Asante-Asamani A, Boakye B, Debrah SA, Ganiyu RA, Enti D, Koggoh P, Kpankpari R, Opandoh INM, Manu MA, Manu MPO, Mensah S, Morna MT, Nortey M, Nkrumah J, Ofori EO, Quartson EM, Acquah AO, Adam-Zakariah LI, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Twerefour EY, Ankomah J, Assah-Adjei F, Boakye AA, Fosu G, Serbeh G, Gyan KY, Nyarko IO, Robertson Z, Acheampong DO, Acquaye J, Adinku M, Agbedinu K, Agbeko AE, Amankwa EG, Amoah M, Amoah G, Appiah J, Arthur J, Ayim A, Ayodeji EK, Boakye-Yiadom J, Boateng EA, Dally C, Davor A, Gyasi-Sarpong CK, Hamidu NNN, Haruna I, Kwarley N, Lovi AK, Nimako B, Nyadu BB, Opoku D, Osabutey A, Sagoe R, Tuffour S, Tufour Y, Yamoah FA, Yefieye AC, Yorke J, Addo KG, Akosa EA, Boakye P, Coompson CL, Gyamfi B, Kontor BE, Kyeremeh C, Manu R, Mensah E, Solae FI, Toffah GK, Adu-Brobbey R, Coompson CL, Labaran AH, Owusu JA, Adobea V, Bennin A, Dankwah F, Doe S, Kantanka RS, Kobby E, Larnyor H, Owusu PY, Sie-Broni CA, Zume M, Abantanga FA, Abdulai DR, Acquah DK, Ayingayure E, Osman I, Kunfah S, Limann G, Mohammed SA, Mohammed S, Musah Y, Ofori B, Owusu EA, Saba AH, Seidu AS, Yakubu M, Yenli EMTA, Bhatti K, Dhiman J, Dhir K, Hans M, Haque PD, Jesudason EDM, Madankumar L, Mittal R, Nagomy I, Prasad S, Dasari A, Jacob P, Kurien E, Mathew A, Prakash D, Susan A, Varghese R, Ortiz RC, Gonzalez GH, Krauss RH, Miguelena LH, Romero MH, Gomez IB, Aguirre CC, Avendaño AC, Sansores LD, Mejia HO, Campo LUGD, Sánchez ID, Vazquez DG, Lara MM, Maldonado LMP, Fuente ANSDL, Medina ARDL, Adeleye V, Adeniyi O, Akinajo O, Akinboyewa D, Alasi I, Alakaloko F, Atoyebi O, Balogun O, Belie O, Bode C, Ekwesianya A, Elebute O, Ezenwankwo F, Fatuga A, Ihediwa G, Jimoh A, Kuku J, Ladipo-Ajayi O, Makanjuola A, Mokwenyei O, Nwokocha S, Ogein O, Ojewola R, Oladimeji A, Olajide T, Oluseye O, Seyi-Olajide J, Soibi-Harry A, Ugwu A, Williams E, Abdur-Rahman L, Adeleke N, Adesola M, Afolabi R, Agodirin S, Aremu I, Bello J, Lawal S, Lawal A, Raji H, Sayomi O, Shittu A, Acquah R, Banka C, Esssien D, Hussey R, Mustapha Y, Nunoo-Ghartey K, Yeboah G, Aniakwo LA, Adjei MNM, Adofo-Asamoah Y, Agyapong MM, Agyen T, Alhassan BAB, Amoako-Boateng MP, Appiah AB, Ashong J, Awindaogo JK, Brimpong BB, Dayie MSCJK, Enti D, Ghansah WW, Gyamfi JE, Koggoh P, Kpankpari R, Kudoh V, Mensah P, Opandoh INM, Morna MT, Nortey M, Odame E, Ofori EO, Quaicoo S, Quartson EM, Teye-Topey C, Yigah M, Yussif S, Adjei-Acquah E, Agyekum-Gyimah VO, Agyemang E, AkotoAmpaw A, Amponsah-Manu F, Arkorful TE, Dokurugu MA, Essel N, Ijeoma A, Obiri EL, Ofosu-Akromah R, Quarchey KND, Adam-Zakariah L, Andoh AB, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Naah A, Oppon-Acquah A, Oppong BA, Agbowada EA, Akosua A, Armah R, Asare C, Awere-Kyere LKB, Bruce-Adjei A, Christian NA, Gakpetor DA, Kennedy KK, Mends-Odro J, Obbeng A, Ofosuhene D, Osei-Poku D, Robertson Z, Ciociano MCJMC, Valle CJZFD, Aziz HIAG, Calvillo MDCG, Iriarte DGIM, Namur LDCM, Medina ARDL, Mustapha BKLA, Utumatwishima AMJN, Abdul-Aziz IIA, Anasara GAG, Ogudi DKD, Quansah JIK, Kumar NAU, Mehraj IMA, Nayak SMP, Díaz KVA, Herrera VJA, Camacho FJB, Pérez IVB, Llamas MAC, Cardona GAC, Andrade LRC, Flores AOC, Torres EJC, Valadez TAC, Valadez AEC, Cardoza JAF, González LAG, Bojorquez JLG, Ponce FYG, Ramírez CSG, Barba JAG, Ramírez BGG, Ruvalcaba MJG, Alva DAH, Camargo SAI, Peña JCI, Pérez ZML, Tellez MPM, Ackerman RCM, Vallejo LRP, Bocanegra VHP, Navarro JVP, Posada FJP, Hernández MAQ, Gonzalez LRR, Elizalde EAR, Ascencio EVR, Velasco CBR, Martínez JAS, Pulido JIS, García AGS, Carreón LOS, Ávila JJT, Gastelum JOV, Ramirez MLV, Casas MFZ, Mata JAA, Vanegas MAC, Arias RGC, Barajas BVE, Angeles LOM, Lomeli AFM, Navarro JEO, Baolboa LGP, Dominguez ACG, Morales JFM, Pesquera JAA, Maldonado LMP, Fonseca RKC, Hernandez EEL, Ramirez JAR, Moscoso MRB, Duniya SAN, Adeleye GTC, Bakare TIB, Ohemu AA, Habumuremyi DUS, Seneza GNC, Haragirimana JDD, Ingabire AJC, Ekwunife OH, Acheampong DO, Agbeko AE, Gyamfi FE, Nyadu BB, Adu-Aryee NA, Amoako JK, Aperkor NT, Asman WK, Attepor GS, Bediako-Bowan AA, Brown GD, Etwire VK, Fenu BS, Kumassah PK, Larbi-Siaw LA, Olatola DO, Tsatsu SE, Barimah CG, Boateng GC, Kwabena PW, Kwarteng SM, Luri PT, Kantanka RS, Owusu PY, Acquah DK, Adams SM, Alhassan MS, Asirifi SA, Dery MK, Ofori BA, Sam NB, Seidu AS, Acquah EK, Coompson CL, Gyambibi AK, Kontor BE, Poonia DR, Rathod KK, Rodha MS, Soni SC, Varsheney VK, Vishnoi JR, Garnaik DK, Lokavarapu MJ, Seenivasagam RK, Kalyanapu JA, Gautham AK, Singh DS, Abraham ES, Gold CS, Joseph JN, Kurien EN, Mathew AJ, Mathew AE, Prakash DD, Hans MA, Haque PD, Sam VD, Thind RS, Veetil SK, Daniel ER, Jacob SE, Jesudason MR, Samuel VM, Sivakumar MV, Saluja SS, Attri AK, Pai MV, Prabhu PS, T SP, Alexander PV, Ismavel VA, Solomi CV, Alpheus RA, Choudhrie AV, Gunny RJ, Malik MA, Peters NJ, Chowdri NA, Dar RA, Parray FQ, Shah ZA, Wani RA, Villaseñor SA, Hernández AB, Ahumada EB, Cardiel GC, Guevara GC, Perez EC, Martinez EC, Barradas PD, Estrada IE, Becerril PF, Orozco CF, Reyna BG, Sánchez EG, Espinoza EG, Ojeda AG, Torres MI, Tornero JJ, País RM, Santana DM, Villela GM, Hinojosa RN, Escobar CN, Rodríguez IO, Flores OO, Barreiro AO, Rubio JO, Bravo CR, Villaseñor GS, Tinajero CC, Samano FD, Banuelos GG, Ortiz FI, Ramirez ML, Arroyo GL, Perez JO, Ramirez DO, Lozano JP, Reyes GY, Castillo MN, Mellado DH, Bozada-Gutierrez K, Casado-Zarate AF, Delano-Alonso R, Herrera-Esquivel J, Moreno-Portillo M, Trejo-Avila M, Quiros BC, Ambriz-González G, Cabrera-Lozano I, Calderón-Alvarado AB, León-Frutos FJ, Villanueva-Martínez EE, Aliyu MS, Balogun AO, Francis AA, Duromola KM, Gana SG, George MD, Iji LO, Jimoh AO, Koledade AK, Lawal AT, Nwabuoku SE, Ogunsua OO, Okafor IF, Okorie EI, Saidu IA, Sholadoye TT, Abdulkarim AA, Abdullahi LB, Tolani MA, Tukur AM, Umar AS, Umar AM, Yusuf SA, Ado KA, Aliyu NU, Anyanwu LJC, Daneji SM, Magashi MK, Mohammad MA, Muhammad AB, Muhammad SS, Muideen BA, Nwachukwu CU, Sallau SB, Sheshe AA, Takai IU, Umar GI, Adze JA, Airede LR, Bature SB, Galadima MC, Hamza BK, Kache SA, Kagomi WY, Kene IA, Makama JG, Mohammed-Durosinlorun AA, Taingson MC, Odunafolabi TA, Okereke CE, Oladele OO, Olaleye OH, Olubayo OO, Abiola OP, Abiyere HO, Adebara IO, Adeniyi AA, Adewara OE, Adeyemo OT, Adeyeye AA, Ariyibi AL, Awoyinka BS, Ayankunle OM, Babalola OF, Banjo OO, Egharevba PA, Fatudimu OS, Obateru JA, Odesanya OJ, Ojo OD, Okunlola AI, Okunlola CK, Olajide AT, Orewole TO, Salawu AI, Abdulsalam MA, Adelaja AT, Ajai OT, Atobatele KM, Bakare OO, Faboya OM, Imam ZO, Nwaenyi FC, Ogunyemi AA, Oludara MA, Omisanjo OA, Onyeka CU, Oshodi OA, Oshodi YA, Salami OS, Williams OM, Adeyeye VI, Agbulu MV, Akinajo OR, Akinboyewa DO, Alakaloko FM, Alasi IO, Atoyebi OA, Balogun OS, Bode CO, Busari MO, Duru NJ, Edet GB, Elebute OA, Ezenwankwo FC, Fatuga AL, Ihediwa GC, Inyang ES, Jimoh AI, Kuku JO, Ladipo-Ajayi OA, Lawal AO, Makwe CC, Mgbemena CV, Nwokocha SU, Ogunjimi MA, Ohazurike EO, Ojewola RW, Badedale ME, Okeke CJ, Okunowo AA, Oladimeji AT, Olajide TO, Oluseye OO, Orowale AA, Osinowo AO, Oyegbola CB, Seyi-Olajide JO, Soibi-Harry AP, Timo MT, Ugwu AO, Williams EO, Duruewuru IO, Egwuonwu OA, Emeka JJ, Modekwe VI, Nwosu CD, Obiechina SO, Obiesie AE, Okafor CI, Okonoboh TO, Okoye OA, Onu OA, Onyejiaka CC, Uche CF, Ugboajah JO, Ugwu JO, Adeleke AA, Adepiti AC, Aderounmu AA, Adesunkanmi AO, Adisa AO, Ajekwu SC, Ajenifuja OK, Alatise OI, Badmus TA, Mohammed TO, Salako AA, Sowande OA, Talabi AO, Wuraola FO, Adegoke PA, Eseile IS, Ogundoyin OO, Olulana DI, Adumah CC, Ajagbe AO, Akintunde OP, Asafa OQ, Eziyi AK, Fasanu AO, Ojewuyi OO, Ojewuyi AR, Oyedele AE, Taiwo OA, Abdullahi HI, Adewole ND, Agida TE, Ailunia EE, Akaba GO, Bawa KG, Chinda JY, Daluk EB, Eniola SB, Ezenwa AO, Garba SE, Mshelbwala PM, Ndukwe NO, Ogolekwu IP, Osagie OO, Sani SA, Tabuanu NO, Umar AM, Agbonrofo PI, Arekhandia AI, Edena ME, Eghonghon RA, Enaholo JE, Ideh SN, Iribhogbe OI, Irowa OO, Isikhuemen ME, Odutola OR, Okoduwa KO, Omorogbe SO, Osagie OT, Abdus-Salam RA, Adebayo SA, Ajagbe OA, Ajao AE, Ayandipo OO, Egbuchulem KI, Ekwuazi HO, Idowu OC, Irabor DO, Lawal TA, Lawal OO, Ogundoyin OO, Sanusi AT, Takure AO, Abdur-Rahman LO, Adebisi MO, Adeleke NA, Afolabi RT, Aremu II, Bello JO, Lawal SA, Raji HO, Igwe PO, Iweha IE, John RE, Okoro PE, Oriji VK, Oweredaba IT, Majyabere JP, Habiyakare JA, Nabada MG, Masengesho JP, Niyomuremyi JP, Uwimana JC, Maniraguha HL, Urimubabo CJ, Shyirakera JY, Adams MA, Ede CJ, Mathe MN, Nhlabathi NA, Nxumalo HS, Sethoana ME, Acquaye J, Appiah J, Arthur J, Boakye-Yiadom J, Abdulai S, Agboadoh N, Akoto E, Boakye-Yiadom K, Dedey F, Nsaful J, Wordui T, Abubakari F, Akunyam J, Ballu C, Ngaaso K, Adobea V, Bennin A, Doe S, Kobby E, Kyeremeh C, Osei E, Owusu F, Sie-Broni C, Zume M, Abdul-Hafiz S, Amadu M, Awe M, Azanlerigu M, Edwin Y, Limann G, Maalekuu A, Malechi H, Mohammed S, Mohammed I, Mumuni K, Yahaya S, Alhassan J, Boakye P, Jeffery-Felix A, Manu R, Mensah E, Naah G, Noufuentes C, Sakyi A, Chaudhary R, Misra S, Pareek P, Pathak M, Sharma N, Sharma N, Huda F, Mishra N, Ranjan R, Singh S, Solanki P, Verma R, Yhoshu E, John S, Kutma A, Philips S, Hepzibah A, Mary G, Chetana C, Dasari A, Dummala P, Jacob J, Mary P, Samuel O, Sukumar A, Syam N, Varghese R, Bhatt A, Bhatti W, Dhar T, Goyal A, Goyal S, Jain D, Jain R, Kaur S, Kumar K, Luther A, Mahajan A, Mandrelle K, Michael V, Mukherjee P, Rajappa R, Singh P, Suroy A, Williams R, D S, Kumari P, Mittal R, Prasad S, Shankar B, Sharma S, Surendran S, Thomas A, Trinity P, Kanchodu S, Leshiini K, Bansal I, Gupta S, Gureh M, Kapoor S, Aggarwal M, Kanna V, Kaur H, Kumar A, Singh S, Singh G, John V, Adnan M, Kumar P, S A, Sehrawat V, Singla D, Thami G, Kumar V, Mathew S, Akhtar N, Chaturvedi A, Gupta S, Kumar V, Prakash P, Rajan S, Singh M, Tripathi A, Thomas J, Zechariah P, Kichu M, Joseph S, Pundir N, Samujh R, Kour R, Saqib N, Raul S, Rautela K, Sharma R, Singh N, Vakil R, Chowdhury P, Chowdhury S, Roy B, Abdullahi A, Abubakar M, Awaisu M, Bakari F, Bashir M, Bello A, Daniyan M, Gimba J, Gundu I, Oyelowo N, Sufyan I, Umaru-Sule H, Usman M, Yahya A, Yakubu A, Abdullahi M, Soladoye A, Yahaya A, Abdulrasheed L, Aminu B, Bello-Tukur F, Chinyio D, Joshua S, Lawal J, Mohammed C, Nuwam D, Sale D, Sani A, Tabara S, Usam E, Yakubu J, Adegoke F, Ige O, Bakare A, Akande O, Anyanwu N, Eke G, Oyewole Y, Abunimye E, Adeoluwa A, Adesiyakan A, Amao M, Ashley-Osuzoka C, Gbenga-Oke C, Makanjuola A, Olanrewaju O, Olayioye O, Olutola S, Onyekachi K, Osariemen E, Osunwusi B, Owie E, Okoro C, Ugwuanyi K, Ugwunne C, Olasehinde O, Akinloye A, Akinniyi A, Ejimogu J, Okedare A, Omotola O, Sanwo F, Awodele K, Aisuodionoe-Shadrach O, Alfred J, Atim T, Mbajiekwe N, Olori A, Suleiman S, Sunday H, Ida G, Oruade D, Osemwegie O, Ajibola G, Elemile P, Fakoya A, Ojediran O, Olagunju N, Bello R, Lawal A, Ojajuni A, Oyewale S, Sayomi O, Shittu A, Abhulimen V, Okoi N, Mizero J, Mutimamwiza I, Nirere F, Niyongombwa I, Byaruhanga A, Dukuzimana R, Uwizeye M, Ruhosha M, Igiraneza J, Ingabire F, Karekezi A, Mpirimbanyi C, Mukamazera L, Mukangabo C, Imanishimwe A, Kanyarukiko S, Mukaneza F, Mukantibaziyaremye D, Munyaneza A, Ndegamiye G, Nyirangeri P, Tubasiime R, Dusabe M, Izabiriza E, Mpirimbanyi C, Mutuyimana J, Mwenedata O, Rwagahirima E, Zirikana J, Sibomana I, Rubanguka D, Umuhoza J, Uwayezu R, Uzikwambara L, Dieudonne A, Kabanda E, Mbonimpaye S, Mukakomite C, Muroruhirwe P, Butana H, Dusabeyezu M, Batangana M, Bucyibaruta G, Habumuremyi S, Imanishimwe A, Mukanyange V, Munyaneza E, Mutabazi E, Mwungura E, Ncogoza I, Ntirenganya F, Nyirahabimana J, Nyirasebura D, Dusabimana A, Kanyesigye S, Munyaneza R, Fourtounas M, Hyman G, Moore R, Sentholang N, Wondoh P, Ally Z, Domingo A, Munda P, Nyatsambo C, Ojo V, Pswarayi R, Cook J, Jayne D, Laurberg S, Brown J, Smart N, Cousens S. Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries. Lancet Glob Health 2024; 12:e235-e242. [PMID: 38245114 DOI: 10.1016/s2214-109x(23)00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 10/17/2023] [Accepted: 11/07/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI. METHODS A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI). FINDINGS In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana. INTERPRETATION Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs. FUNDING National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.
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Qiu X, Zhao Y, Jia Z, Li C, Jin R, Mutabazi E. Fe and Zn co-doped carbon nanoparticles as peroxymonosulfate activator for efficient 2,4-dichorophenol degradation. Environ Res 2024; 240:117313. [PMID: 37866532 DOI: 10.1016/j.envres.2023.117313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/17/2023] [Accepted: 09/29/2023] [Indexed: 10/24/2023]
Abstract
Iron-mediated activation of peroxymonosulfate (PMS) has been of great interest for the effective removal of contaminants, but it still suffered from ineffective metal redox cycle rate, which resulted in unsatisfactory catalytic efficiency. Constructing bimetallic carbonaceous materials was effective way to improve the catalytic performance of iron-based heterogeneous system. In this study, magnetic bimetallic porous carbon composite (FZCx) was synthesized via Fe/Zn bi-MOFs pyrolysis for 2,4-dichlorophenol (2,4-DCP) degradation by peroxymonosulfate. Influences of different systems exhibited that 100% of 2,4-DCP was rapidly degraded at the conditions of catalyst dosage = 0.1 g L-1, PMS = 0.5 mM and initial pH = 9.0 within 30 min. The as-prepared FZC600 displayed excellent reusability and stability. Quenching experiments and EPR analysis manifested that SO4·- and 1O2 were primarily responsible for the rapid degradation of 2,4-DCP. Moreover, XPS, EPR and EIS was used to elaborate the bimetallic synergy effect, proving that the introduction of zinc can effectively promote periodic cycle of Fe2+/Fe3+ and improve catalysts durability and reusability. These findings highlighted the preparation of bimetallic based carbonaceous material with excellent PMS activation ability to remove refractory organics from wastewater and provided a depth insight into the promotion of bimetal synergy between zinc and iron on PMS activation process.
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Affiliation(s)
- Xiaojie Qiu
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
| | - Yingxin Zhao
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China.
| | - Zichen Jia
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
| | - Chenxi Li
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
| | - Ruotong Jin
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
| | - Emmanuel Mutabazi
- School of Environmental Science and Engineering, Tianjin University, Tianjin, 300350, China
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Glasbey JC, Kadir B, Ademuyiwa AO, Adisa AO, Bhangu A, Brocklehurst P, Chakrabortee S, Hardy P, Harrison E, Ingabire JCA, Haque PD, Ismail L, Ghosh D, Gyamfi FE, Li E, Lillywhite R, de la Medina AR, Moore R, Magill L, Morton D, Nepogodiev D, Ntirenganya F, Pinkney T, Omar O, Simoes JFF, Smith D, Tabiri S, Runigamugabo E, Sodonougbo P, Behanzin H, Kangni S, Agboton G, Adagrah LA, Adjei-Acquah E, Acquah AO, Ankomah J, Armah R, Acquah R, Addo KG, Acheampong DO, Adu-Aryee NA, Abubakari F, Titigah A, Owusu F, Adu-Brobbey R, Adobea V, Abantanga FA, Gautham A, Bhatti D, Jesudason EDM, Aggarwal M, Alexander P, Dasari A, Alpheus R, Kumar H, Raul S, Bueno WÁ, Ortiz RC, Gomez IB, Cerdan CC, Gallo MB, Gamez RR, Sánchez ID, Abdullahi L, Adesanya O, Abdulsalam M, Adeleye V, Egwuonwu O, Adeleke A, Adebayo F, Chiejina G, Abayomi O, Abdur-Rahman L, Ede J, Ezinne U, Kanyarukiko S, Dusabe M, Hirwa AD, Bucyibaruta G, Adams MA, Birtles C, Ally Z, Adewunmi AS, Cook J, Brown J, Verjee A, Assouto P, Seto DM, Kpangon C, Ahossi R, Alhassan BBA, Agyekum V, Adam-Zakariah LI, Assah-Adjei F, Asare C, Amoako J, Akosa EA, Acquaye J, Adjei F, Ballu C, Coompson CL, Bennin A, Abdulai DR, Hepzibah A, Bhatti W, Paul PK, Dhamija P, Thomas J, Jacob P, Choudhrie A, Peters N, Sharma R, Camacho FB, Gonzalez GH, Aguirre CC, Solano DD, Flores AC, Menindez RL, Vazquez DG, Ado K, Awonuga D, Adeniran A, Ademuyiwa A, Ekwunife O, Adenikinju W, Aisuodionoe-Shadrach O, Edet E, Abdus-Salam R, Adeleke N, Ekenze S, Francis M, Mukaneza F, Izabiriza E, Kabanda E, Bunogerane GJ, Crawford R, Ivy M, Jayne D, Cousens S, Brant F, Fiogbe M, Tandje Y, Akpla M, Ngabo RB, Amoako-Boateng MP, Agyemang E, Asabre E, Boakye AA, Gakpetor DA, Appiah AD, Boakye P, Adinku M, Akoto E, Barimah CG, Labaran AH, Dankwah F, Acquah DK, Mary G, Bir K, Madankumar L, Gupta H, Zechariah P, Kurien E, Vakil R, Hernández AB, Krauss RH, Avendaño AC, Garcia RT, Ojeda AG, Peón AN, Lara MM, Aliyu M, Fasiku O, Ajai O, Adeniyi O, Modekwe V, Adeniyi O, Akaba G, Inyang A, Adebayo S, Adesola M, Enemuo V, Ikechukwu I, Mukantibaziyaremye D, Maniraguha HL, Mbonimpaye S, Habumuremyi S, Ede CJ, Mbavhalelo C, Laurberg S, Smart N, Koco H, Chobli HH, Bisimwa N, Appiah AB, Akesseh RA, Boateng RA, Fosu G, Gawu VS, Aseti M, Coompson CL, Agbedinu K, Ametefe E, Boateng GC, Owusu JA, Doe S, Ayingayure E, Singh D, Daniel S, Mittal R, Kanna V, Mathew A, Arellano AB, Miguelena LH, Sansores LD, Velasco MJ, Muñoz MP, Perez-Maldonado LM, Anyanwu LJ, Ogo C, Akande O, Akinajo O, Okoro C, Adepiti A, Ameh L, Isa M, Ajao A, Afolabi R, Eze M, Nnyonno O, Munyaneza A, Mpirimbanyi C, Mukakomite C, Haragirimana JDD, Fourtounas M, Chakrabortee S, Metchinhoungbe S, Kovohouande B, Kandokponou CMB, Asante-Asamani A, Amponsah-Manu F, Koomson B, Serbeh G, Obbeng A, Banka C, Gyamfi B, Agbeko AE, Amoako JK, Luri PT, Kantanka RS, Osman I, Dhar T, Nagomy I, Kumar A, Prakash D, Torres EC, Romero MH, Mejia HO, de la Fuente ANS, Magashi M, Atobatele K, Akinboyewa D, Uche C, Aderounmu A, Mbajiekwe N, Iseh F, Amusat O, Agodirin S, Ezomike U, Okoro P, Ndegamiye G, Mutuyimana J, Muroruhirwe P, Imanishimwe A, Hyman G, Sogbo H, Dokponou M, Boakye B, Ofosu-Akromah R, Kusiwaa A, Gyan KY, Ofosuhene D, Dadzie S, Kontor BE, Amankwa EG, Attepor GS, Kobby E, Kunfah S, Dhiman J, Selvakumar R, Singh G, Susan A, Orozco CF, del Campo LUG, de la Medina ARD, Muhammad A, Eke G, Alasi I, Ugwuanyi K, Adesunkanmi A, Ogbo F, Marwa A, Ayandipo O, Aremu I, Izuka E, Patrick I, Tubasiime R, Mwenedata O, Ingabire JCA, Khan Z, Dossou FM, Debrah SA, Enti D, Twerefour EY, Nyarko IO, Osei-Poku D, Essien D, Kyeremeh C, Amoah M, Brown GD, Larnyor KKKH, Limann G, Ghosh D, Shankar B, Varghese R, de Rojas EGG, Muhammad S, Faboya O, Alakaloko F, Ugwunne C, Adisa A, Olori S, Ogbeche S, Egbuchulem K, Bello J, Mbadiwe O, Raphael J, Rwagahirima E, Mukanyange V, Kwati M, Dzemta C, Ganiyu RA, Robertson Z, Puozaa D, Gyamfi FE, Manu R, Amoah G, Fenu B, Osei E, Mohammed SA, Goyal S, Sivakumar M, Ojeda AG, Muideen B, Imam Z, Atoyebi O, Ajekwu S, Osagie O, Olory E, Ekwuazi H, Lawal S, Mbah N, Vaduneme O, Uwizeyimana F, Munyaneza E, Mathe MN, Gaou A, Koggoh P, Tackie E, Hussey R, Mensah E, Appiah J, Kumassah PK, Owusu PY, Mohammed S, Goyal A, Sridhar R, Ramírez BG, Takai I, Momson E, Balogun O, Ajenjfuja O, Sadiq A, Udie G, Elemile P, Lawal A, Victor A, Zirikana J, Mutabazi E, Moore R, Heritage E, Goudou R, Kpankpari R, Temitope AE, Kwarteng J, Solae FI, Arthur J, Olayiwola DO, Sie-Broni CA, Musah Y, Goyal S, Thomas C, Valadez MHV, Ukata O, Nwaenyi F, Belie O, Akindojutimi J, Sani S, Udosen J, Lawal T, Raji H, Ncogoza I, Nhlabathi NA, Hedefoun E, Opandoh INM, Sowah NA, Toffah GK, Ayim A, Wordui T, Zume M, Ofori B, Hans M, Titus D, Acevedo DL, Ogunyemi A, Bode C, Akinkuolie A, Tabuanu N, Usang U, Lawal O, Sayomi O, Ntirenganya F, Nxumalo HS, Kroese K, Houtoukpe S, Manu MA, Yeboah G, Ayodeji EK, Agboadoh N, Owusu EA, Haque P, Galaviz RM, Oludara M, Ekwesianya A, Alatise O, Uanikhoba M, Olagunju S, Shittu A, Nyirahabimana J, Pattinson P, Lapitan C, Kamga F, Manu MPO, Yeboah C, Boakye-Yiadom J, Saba AH, Konda S, Flores OO, Omisanjo O, Elebute O, Allen O, Osuala P, Urimubabo C, Sentholang N, Kiki-Migan E, Mensah S, Boateng EA, Seidu AS, Luther A, Navarro JP, Oshodi O, Ezenwankwo F, Amosu L, Suleman B, Sethoana ME, Lissauer D, Lawani S, Morna MT, Dally C, Tabiri S, Mahajan A, Belmontes KP, Oshodi Y, Fatuga A, Archibong M, Takure A, Stassen ME, Lawani I, Nkrumah J, Davor A, Yakubu M, Makkar S, Marbello FR, Oyewole Y, Ihediwa G, Arowolo O, Thornley L, Loko R, Nortey M, Gyasi-Sarpong CK, Yenli EMTA, Mandrelle K, Ramírez-González L, Salami O, Jimoh A, Ayantona D, Wondoh P, Mistry P, Moutaïrou A, Ofori EO, Hamidu NNN, Michael V, Aguirre LR, Williams O, Kuku J, Ayinde A, Monahan M, Ogouyemi P, Quartson EMQ, Haruna I, Mukherjee P, García RR, Ladipo-Ajayi O, Badejoko O, Soumanou F, Kwarley N, Rajappa R, Robles EV, Makanjuola A, Badmus T, Tamadaho P, Lovi AK, Singh P, Mokwenyei O, Etonyeaku A, Zounon MA, Nimako B, Suroy A, Nwokocha S, Igbodike E, Nyadu BB, Thind R, Ogein O, Ijarotimi O, Opoku D, Thomas A, Ojewola R, Lawal A, Osabutey A, Tuli A, Oladimeji A, Nana F, Roberts T, Sagoe R, Veetil S, Olajide T, Oduanafolabi T, Tuffour S, Oluseye O, Olasehinde O, Tufour Y, Seyi-Olajide J, Olayemi O, Winkles N, Yamoah FA, Soibi-Harry A, Omitinde S, Yefieye AC, Ugwu A, Oni O, Yorke J, Williams E, Onyeze C, Orji E, Rotimi A, Salako A, Solaja O, Sowemimo O, Talabi A, Tajudeen M, Wuraola F. The importance of post-discharge surgical site infection surveillance: an exploration of surrogate outcome validity in a global randomised controlled trial (FALCON). Lancet Glob Health 2023; 11:e1178-e1179. [PMID: 37474222 DOI: 10.1016/s2214-109x(23)00256-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/05/2023] [Accepted: 05/26/2023] [Indexed: 07/22/2023]
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Alayande BT, Forbes CW, Iradakunda J, Majyambere JP, Hey MT, Powell BL, Perl J, McCall N, Paul T, Ingabire JA, Shimelash N, Mutabazi E, Kimto EO, Danladi GM, Tubasiime R, Rickard J, Karekezi C, Makiriro G, Bigirimana SP, Harelimana JG, ElSayed A, Ndibanje AJ, Mpirimbanyi C, Masimbi O, Ndayishimiye M, Ntabana F, Haonga BT, Anderson GA, Byringyiro JC, Ntirenganya F, Riviello RR, Bekele A. Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference. Cureus 2023; 15:e43625. [PMID: 37600431 PMCID: PMC10433784 DOI: 10.7759/cureus.43625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/22/2023] Open
Abstract
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.
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Affiliation(s)
- Barnabas T Alayande
- General Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Global Health and Population, Harvard School of Public Health, Boston, USA
| | - Callum W Forbes
- Anesthesiology, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Jules Iradakunda
- School of Medicine, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Jean Paul Majyambere
- General Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Surgery, Butaro District Hospital, Kigali, RWA
| | - Matthew T Hey
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Brittany L Powell
- Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Juliana Perl
- Biodesign, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Natalie McCall
- Division of Clinical Medicine, University of Global Health Equity, Kigali, RWA
| | - Tomlin Paul
- Educational Development and Quality Center, University of Global Health Equity, Kigali, RWA
| | - Jc Allen Ingabire
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | - Natnael Shimelash
- Biodesign, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Emmanuel Mutabazi
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | | | | | | | | | - Claire Karekezi
- Surgery, Neurosurgery Unit, Rwanda Military Hospital, Kigali, RWA
| | - Gabriel Makiriro
- Division of Clinical Medicine, University of Global Health Equity, Kigali, RWA
| | - Simon Pierre Bigirimana
- School of Medicine, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - James G Harelimana
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | | | | | | | - Ornella Masimbi
- Simulation, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | | | - Frederick Ntabana
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | - Billy Thomson Haonga
- Orthopaedic Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, TZA
| | - Geoffrey A Anderson
- Trauma, Burns, and Critical Care, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Jean Claude Byringyiro
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
- Orthopedics, University Teaching Hospital of Kigali, Kigali, RWA
| | - Faustin Ntirenganya
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
- Surgery, University Teaching Hospital of Kigali, Kigali, RWA
- NIHR Research Hub on Global Surgery, University of Rwanda, Kigali, RWA
| | - Robert R Riviello
- Trauma, Burns, and Critical Care, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Kigali, RWA
| | - Abebe Bekele
- Cardiothoracic Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
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Wang Q, Zhao Y, Zhang C, Zhao M, Jia X, Mutabazi E, Liu Y. New insights into hexavalent chromium exposure in electron donor limited denitrification: bio-electron behavior. Bioresour Technol 2023; 380:129088. [PMID: 37094618 DOI: 10.1016/j.biortech.2023.129088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/03/2023]
Abstract
The bio-electron behavior (electron production, transmission, and consumption) response to a typical heavy metal, hexavalent chromium, was unraveled in the electron donor limited system (EDLS) and electron donor sufficient system (EDSS). Nicotinamide adenine dinucleotide and adenosine triphosphate production were reduced by 44% and 47%, respectively, due to glucose metabolism inhibition, leading to NO3--N declining to 31% in EDLS. The decreased electron carrier contents and denitrifying enzymes activity inhibited electron transmission and consumption in both EDLS and EDSS. Additionally, electron transfer and antioxidant stress abilities were reduced, further hindering the survival of denitrifiers in EDLS. The lack of dominant genera (Comamonas, Thermomonas, and Microbacterium) in EDLS was the primary reason for poor biofilm formation and chromium adaptability. The decreased expression of enzymes related to glucose metabolism caused the imbalance of electron supply, transport, and consumption in EDLS, adversely impacting nitrogen metabolism and inhibiting denitrification performance.
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Affiliation(s)
- Qian Wang
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
| | - Yingxin Zhao
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China.
| | - Chenggong Zhang
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
| | - Minghao Zhao
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
| | - Xulong Jia
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
| | - Emmanuel Mutabazi
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
| | - Yiwen Liu
- School of Environmental Science and Engineering, Tianjin University, Tianjin 300350, China
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Ahogni D, Ahounou A, Boukari KA, Gbehade O, Hessou TK, Nindopa S, Nontonwanou MJB, Guessou NO, Sambo A, Tchati SV, Tchogo A, Tobome SR, Yanto P, Gandaho I, Hadonou A, Hinvo S, Hodonou MA, Tamou SB, Lawani S, Kandokponou CMB, Dossou FM, Gaou A, Goudou R, Kouroumta MC, Lawani I, Malade E, Dikao ASM, Nsilu JN, Ogouyemi P, Akpla M, Mitima NB, Kovohouande B, Kpangon C, Loupeda SL, Agbangla MV, Hedefoun SE, Mavoha T, Ngaguene J, Rugendabanga J, Soton RR, Totin M, Agbadebo M, Akpo I, Dewamon H, Djeto M, Hada A, Hollo M, Houndji A, Houndote A, Hounsa S, Kpatchassou E, Yome H, Alidou MM, Bara EJ, Yovo BTBD, Guinnou R, Hamadou S, Kola HP, Moussa N, Cakpo B, Etchisse L, Hatangimana E, Muhindo M, Sanni K, Yevide AB, Agossou H, Musengo FB, Behanzin H, Seto DM, Alia BA, Alitonou A, Mehounou YE, Agbanda L, Attinon J, Gbassi M, Hounsou NR, Acquah R, Banka C, Esssien D, Hussey R, Mustapha Y, Nunoo-Ghartey K, Yeboah G, Aniakwo LA, Adjei MNM, Adofo-Asamoah Y, Agyapong MM, Agyen T, Alhassan BAB, Amoako-Boateng MP, Appiah AB, Ashong J, Awindaogo JK, Brimpong BB, Dayie MSCJK, Enti D, Ghansah WW, Gyamfi JE, Koggoh P, Kpankpari R, Kudoh V, Mensah S, Mensah P, Morkor Opandoh IN, Morna MT, Nortey M, Odame E, Ofori EO, Quaicoo S, Quartson EM, Teye-Topey C, Yigah M, Yussif S, Adjei-Acquah E, Agyekum-Gyimah VO, Agyemang E, Akoto-Ampaw A, Amponsah-Manu F, Arkorful TE, Dokurugu MA, Essel N, Ijeoma A, Obiri EL, Ofosu-Akromah R, Quarchey KND, Adam-Zakariah L, Andoh AB, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Naah A, Oppon-Acquah A, Oppong BA, Agbowada EA, Akosua A, Armah R, Asare C, Awere-Kyere LKB, Bruce-Adjei A, Christian NA, Gakpetor DA, Kennedy KK, Mends-Odro J, Obbeng A, Ofosuhene D, Osei-Poku D, Robertson Z, Acheampong DO, Acquaye J, Appiah J, Arthur J, Boakye-Yiadom J, Agbeko AE, Gyamfi FE, Nyadu BB, Abdulai S, Adu-Aryee NA, Agboadoh N, Akoto E, Amoako JK, Aperkor NT, Asman WK, Attepor GS, Bediako-Bowan AA, Boakye-Yiadom K, Brown GD, Dedey F, Etwire VK, Fenu BS, Kumassah PK, Larbi-Siaw LA, Nsaful J, Olatola DO, Tsatsu SE, Wordui T, Abdul-Aziz IIA, Abubakari F, Akunyam J, Anasara GAG, Ballu C, Barimah CG, Boateng GC, Kwabena PW, Kwarteng SM, Luri PT, Ngaaso K, Ogudi DKD, Adobea V, Bennin A, Doe S, Kantanka RS, Kobby E, Kyeremeh C, Osei E, Owusu PY, Owusu F, Sie-Broni C, Zume M, Abdul-Hafiz S, Acquah DK, Adams SM, Alhassan MS, Amadu M, Asirifi SA, Awe M, Azanlerigu M, Dery MK, Edwin Y, Francis AA, Limann G, Maalekuu A, Malechi H, Mohammed S, Mohammed I, Mumuni K, Ofori BA, Quansah JIK, Seidu AS, Tabiri S, Yahaya S, Acquah EK, Alhassan J, Boakye P, Coompson CL, Gyambibi AK, Jeffery-Felix A, Kontor BE, Manu R, Mensah E, Naah G, Noufuentes C, Sakyi A, Chaudhary R, Misra S, Pareek P, Pathak M, Poonia DR, Rathod KK, Rodha MS, Sharma N, Sharma N, Soni SC, Varsheney VK, Vishnoi JR, Garnaik DK, Huda F, Lokavarapu MJ, Mishra N, Ranjan R, Seenivasagam RK, Singh S, Solanki P, Verma R, Yhoshu E, John S, Kalyanapu JA, Kutma A, Philips S, Gautham AK, Hepzibah A, Mary G, Singh DS, Abraham ES, Chetana C, Dasari A, Dummala P, Gold CS, Jacob J, Joseph JN, Kurien EN, Mary P, Mathew AJ, Mathew AE, Prakash DD, Samuel O, Sukumar A, Syam N, Varghese R, Bhatt A, Bhatti W, Dhar T, Ghosh DN, Goyal A, Goyal S, Hans MA, Haque PD, Jain D, Jain R, Jyoti J, Kaur S, Kumar K, Luther A, Mahajan A, Mandrelle K, Michael V, Mukherjee P, Rajappa R, Sam VD, Singh P, Suroy A, Thind RS, Veetil SK, Williams R, Sreekar D, Daniel ER, Jacob SE, Jesudason MR, Kumari P, Mittal R, Prasad S, Samuel VM, Shankar B, Sharma S, Sivakumar MV, Surendran S, Thomas A, Trinity P, Kanchodu S, Leshiini K, Saluja SS, Attri AK, Bansal I, Gupta S, Gureh M, Kapoor S, Aggarwal M, Kanna V, Kaur H, Kumar A, Singh S, Singh G, John V, Adnan M, Agrawal N, Kumar U, Kumar P, Abhishek S, Sehrawat V, Singla D, Thami G, Kumar V, Mathew S, Pai MV, Prabhu PS, Sundeep PT, Akhtar N, Chaturvedi A, Gupta S, Kumar V, Prakash P, Rajan S, Singh M, Tripathi A, Alexander PV, Thomas J, Zechariah P, Ismavel VA, Kichu M, 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MN, Moore R, Nhlabathi NA, Nxumalo HS, Sentholang N, Sethoana ME, Wondoh P, Ally Z, Domingo A, Munda P, Nyatsambo C, Ojo V, Pswarayi R. Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries. Trials 2023; 24:259. [PMID: 37020311 PMCID: PMC10077601 DOI: 10.1186/s13063-022-06852-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/19/2022] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT. METHODS ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment. RESULTS This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment. CONCLUSION cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.
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Andoh AB, Atindaana Francis A, Abdulkarim AA, Adesunkanmi AO, Salako AA, Soladoye A, Sheshe AA, Sani A, Lawal AO, Lawal A, Tripathi A, S A, Akinloye A, Olajumoke Balogun A, Ariyibi AL, Okunlola AI, Ojewuyi AR, Oyedele AE, Sakyi A, Oladimeji AT, Bala Muhammad A, Yahaya A, Soibi-Harry AP, Gyambibi AK, Adeniyi AA, Adeoluwa A, Olumide Osinowo A, Salawu AI, Fatuga AL, Adesiyakan A, Fakoya A, Naah A, Adeyeye AA, Talabi AO, Fasanu AO, Ayoola Orowale A, Ojajuni A, Adelaja AT, Ademuyiwa AO, Jimoh AI, Aderounmu AA, Adisa AO, Ajagbe AO, Olajide AT, Bakare A, Okunowo AA, Tchogo A, Koledade AK, Barthelemy Yevide A, Bello A, Shehu Umar A, Lawal AT, Obiesie AE, Dieudonne Hirwa A, Domingo A, Mustapha A, Abdullahi A, Hada A, Ijeoma A, Adeleke AA, Adepiti AC, Ajao AE, Sanusi AT, Houndji A, Bernal Hernández A, González Ojeda A, Serrano García AG, Ohemu AA, Arekhandia AI, Yakubu A, Hepzibah A, Bhatt A, Muhammad Tukur A, Ingabire AJC, Okechukwu Ugwu A, Karekezi A, Maalekuu A, Imanishimwe A, Bruce-Adjei A, 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Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries. Lancet 2022; 400:1767-1776. [PMID: 36328045 DOI: 10.1016/s0140-6736(22)01884-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/06/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI. METHODS ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749. FINDINGS Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events. INTERPRETATION This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world. FUNDING National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.
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