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Ademuyiwa AO, Adisa A, Allen Ingabire JC, Bhangu AA, Crawford R, Galley F, Ghaffar A, Ghosh D, Glasbey J, Haque P, Ismail L, Kamarajah S, Ledda V, Li E, Morton DG, Nepogodiev D, Ntirenganya F, Picciochi M, Ramos de la Medina A. Prioritizing clean, secure energy for operating theatres in the Global South. Br J Surg 2024; 111:znae086. [PMID: 38651765 DOI: 10.1093/bjs/znae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024]
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Shyaka I, Miranda E, Velin L, Mukagaju F, Nezerwa Y, Ntirenganya F, Furaha C, Riviello R, Pompermaier L. Estimating mortality risk in burn patients admitted at Rwanda's largest referral hospital. Int J Burns Trauma 2024; 14:25-31. [PMID: 38505345 PMCID: PMC10944709] [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] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Ian Shyaka
- Department of Plastic Surgery, Rwanda Military HospitalKigali, Rwanda
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical SchoolBoston, MA, USA
- Division of Vascular Surgery, University of Southern CaliforniaLos Angeles, CA, USA
| | - Lotta Velin
- Program in Global Surgery and Social Change, Harvard Medical SchoolBoston, MA, USA
- Centre for Teaching and Research in Disaster Medicine and Traumatology (KMC), Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | | | - Yves Nezerwa
- Department of Plastic Surgery, Rwanda Military HospitalKigali, Rwanda
| | - Faustin Ntirenganya
- Department of Plastic Surgery, University Teaching Hospital of Kigali (CHUK)Kigali, Rwanda
| | - Charles Furaha
- Department of Plastic Surgery, Rwanda Military HospitalKigali, Rwanda
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical SchoolBoston, MA, USA
- Center for Surgery and Public Health, Brigham and Women’s HospitalBoston, MA, USA
| | - Laura Pompermaier
- Department of Hand and Plastic Surgery and Burn Center, Linköping University HospitalSweden
- Department of Biomedical and Clinical Sciences, Linköping UniversitySweden
- Center for Teaching & Research in Disaster Medicine and Traumatology (KMC)Linköping, Sweden
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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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Ademuyiwa AO, Bhangu A, Chakrabortee S, Glasbey J, Kamarajah SK, Ledda V, Li E, Morton D, Nepogodiev D, Picciochi M, Simoes JFF, Lapitan MC, Cheetham M, Forkman E, El-Boghdadly E, Ghosh D, Harrison EM, Hutchinson P, Lawani I, Aguilera ML, Martin J, Meara JG, Ntirenganya F, Medina ARDL, Tabiri S. Strategies to strengthen elective surgery systems during the SARS-CoV-2 pandemic: systematic review and framework development. Br J Surg 2024; 111:znad405. [PMID: 38300731 PMCID: PMC10833142 DOI: 10.1093/bjs/znad405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/12/2023] [Accepted: 10/27/2023] [Indexed: 02/03/2024]
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Musanabaganwa C, Ruton H, Ruhangaza D, Nsabimana N, Kayitare E, Muvunyi TZ, Semakula M, Ntirenganya F, Musoni E, Ndoli J, Hategekimana E, Nassir A, Makokha F, Uwimana A, Gasana J, Munezero PC, Uwinkindi F, Muvunyi CM, Nyirazinyoye L, Mazarati JB, Mutesa L. An Assessment of the Knowledge and Perceptions of Precision Medicine (PM) in the Rwandan Healthcare Setting. J Pers Med 2023; 13:1707. [PMID: 38138934 PMCID: PMC10744509 DOI: 10.3390/jpm13121707] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 12/24/2023] Open
Abstract
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.
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Affiliation(s)
- Clarisse Musanabaganwa
- Division of Research Innovation and Data Science, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda; (M.S.); (J.G.); (C.M.M.)
- Center of Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 4285, Rwanda
| | - Hinda Ruton
- School of Public Health, University of Rwanda, Kigali P.O. Box 3286, Rwanda; (H.R.); (L.N.)
| | | | - Nicaise Nsabimana
- Butaro District Hospital, Burera P.O. Box 59, Rwanda; (D.R.); (N.N.); (E.K.)
| | - Emmanuel Kayitare
- Butaro District Hospital, Burera P.O. Box 59, Rwanda; (D.R.); (N.N.); (E.K.)
| | | | - Muhammed Semakula
- Division of Research Innovation and Data Science, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda; (M.S.); (J.G.); (C.M.M.)
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali P.O. Box 655, Rwanda; (F.N.); (E.M.)
| | - Emile Musoni
- University Teaching Hospital of Kigali, Kigali P.O. Box 655, Rwanda; (F.N.); (E.M.)
| | - Jules Ndoli
- University Teaching Hospital of Butare, Huye P.O. Box 254, Rwanda; (J.N.); (E.H.)
| | - Elisee Hategekimana
- University Teaching Hospital of Butare, Huye P.O. Box 254, Rwanda; (J.N.); (E.H.)
| | - Angus Nassir
- Kenya Institute of Bioinfomatics, Nairobi P.O. Box 918, Kenya;
| | - Francis Makokha
- Directorate of Research and Development, Mount Kenya University, Thika P.O. Box 342-01000, Kenya;
| | - Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda;
| | - Joel Gasana
- Division of Research Innovation and Data Science, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda; (M.S.); (J.G.); (C.M.M.)
| | - Pierre Celestin Munezero
- Department of Microbiology and Parasitology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Huye P.O. Box 117, Rwanda;
| | - Francois Uwinkindi
- Division of Non-Communicable Diseases, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda;
| | - Claude Mambo Muvunyi
- Division of Research Innovation and Data Science, Rwanda Biomedical Center, Kigali P.O. Box 7162, Rwanda; (M.S.); (J.G.); (C.M.M.)
| | - Laetitia Nyirazinyoye
- School of Public Health, University of Rwanda, Kigali P.O. Box 3286, Rwanda; (H.R.); (L.N.)
| | - Jean Baptiste Mazarati
- School of Medicine, University of Global Health Equity, University of Global Health Equity, Kigali P.O. Box 6955, Rwanda;
| | - Leon Mutesa
- Center of Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 4285, Rwanda
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Bekele A, Alayande BT, Powell BL, Obi N, Seyi-Olajide JO, Riviello RR, Ntirenganya F, Ameh EA, Makasa EM. National Surgical Healthcare Policy Development and Implementation: Where do We Stand in Africa? World J Surg 2023; 47:3020-3029. [PMID: 37550548 DOI: 10.1007/s00268-023-07131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
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.
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Affiliation(s)
- Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
| | - Barnabas Tobi Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda.
- Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Britany L Powell
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Robert R Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali Heights, Plot 772, KG 7 Ave., 5Th Floor, PO Box 6955, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | | | - Emmanuel A Ameh
- Department of Surgery, National Hospital, Central Business District, Abuja, Nigeria
| | - Emmanuel M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, University of the Witwatersrand, Johannesburg, South Africa
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Shyaka I, Nezerwa Y, Mukagaju F, Dang RR, Furaha C, Ntirenganya F. Building Sustainable Reconstructive Microsurgery in Countries with Limited Resources: The Rwandan Experience. Plast Reconstr Surg Glob Open 2023; 11:e5332. [PMID: 37829102 PMCID: PMC10566851 DOI: 10.1097/gox.0000000000005332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- Ian Shyaka
- From the Department of Plastic Surgery, Rwanda Military Hospital, Kigali, Rwanda
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Yves Nezerwa
- From the Department of Plastic Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | | | - Rushil R. Dang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Charles Furaha
- From the Department of Plastic Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Faustin Ntirenganya
- Department of Plastic Surgery, University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
- Department of Surgery, University of Rwanda (UR), Kigali, Rwanda
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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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Adisa A, Bahrami-Hessari M, Bhangu A, George C, Ghosh D, Glasbey J, Haque P, Ingabire JCA, Kamarajah SK, Kudrna L, Ledda V, Li E, Lillywhite R, Mittal R, Nepogodiev D, Ntirenganya F, Picciochi M, Simões JFF, Booth L, Elliot R, Kennerton AS, Pettigrove KL, Pinney L, Richard H, Tottman R, Wheatstone P, Wolfenden JWD, Smith A, Sayed AE, Goswami AG, Malik A, Mclean AL, Hassan A, Nazimi AJ, Aladna A, Abdelgawad A, Saed A, Abdelmageed A, Ghannam A, Mahmoud A, Alvi A, Ismail A, Adesunkanmi A, Ebrahim A, Al-Mallah A, Alqallaf A, Durrani A, Gabr A, Kirfi AM, Altaf A, Almutairi A, Sabbagh AJ, Ajiya A, Haddud A, Alnsour AAM, Singh A, Mittal A, Semple A, Adeniran A, Negussie A, Oladimeji A, Muhammad AB, Yassin A, Gungor A, Tarsitano A, Soibiharry A, Dyas A, Frankel A, Peckham-Cooper A, Truss A, Issaka A, Ads AM, Aderogba AA, Adeyeye A, Ademuyiwa A, Sleem A, Papa A, Cordova A, Appiah-Kubi A, Meead A, Nacion AJD, Michael A, Forneris AA, Duro A, Gonzalez AR, Altouny A, Ghazal A, Khalifa A, Ozair A, Quzli A, Haddad A, Othman AF, Yahaya AS, Elsherbiny A, Nazer A, Tarek A, Abu-Zaid A, Al-Nusairi A, Azab A, Elagili A, Elkazaz A, Kedwany A, Nuhu AM, Sakr A, Shehta A, Shirazi A, Mohamed AMI, Sherif AE, Awad AK, Abbas AM, Abdelrahman AS, Ammar AS, Azzam AY, Ciftci AB, Dural AC, Sanli AN, Rahy-Martín AC, Tantri AR, Khan A, Al-Touny A, Tariq A, Gmati A, Costas-Chavarri A, Auerkari A, Landaluce-Olavarria A, Puri A, Radhakrishnan A, Ubom AE, Pradhan A, Turna A, Adepiti A, Kuriyama A, Kassam AF, Hassouneh A, El-Hussuna A, Habeebullah A, Ads AM, Mousli A, Biloslavo A, Hoang A, Kirk A, Santini A, Melero AV, Calvache AJN, Baduell A, Chan A, Abrate A, Balduzzi A, Sánchez AC, Navarrete-Peón A, Porcu A, Brolese A, Barranquero AG, Saibene AM, Adam AA, Vagge A, Maquilón AJ, Leon-Andrino A, Sekulić A, Trifunovski A, Mako A, Bedada AG, Broglia A, Coppola A, Giani A, Grandi A, Iacomino A, Moro A, D’amico A, Malagnino A, Tang A, Doyle A, Alfieri A, Haynes A, Wilkins A, Baldwin A, Heriot A, Laird A, Lazarides A, O'connor A, Trulson A, Rokohl AC, Caziuc A, Triantafyllou A, Anesi A, Nikova A, Andrianakis A, Charalabopoulos A, Tsolakidis A, Chirca A, Arnaud AP, Narvaez-Rojas AR, Kavalakat A, Spina A, Recordare A, Annicchiarico A, Conti A, Mohammed AD, Kocataş A, Almhimid A, Arnaout A, Fahmy A, Mangi A, Modabber A, Ulas AB, Mohamedahmed AYY, Frontali A, Moynihan A, Yunus A, Ahmad A, Kent AJ, Khamees A, Ugwu AO, Turan A, Mohammed AAK, Navarro-Barrios A, Yebes A, De Sousa ÁFL, Moreno A, Sethi A, Dawson AC, Othman AAA, Kaur A, Wolde A, Antonelli A, Scifo A, Alhamad A, Davis A, Alderazi A, Harky A, Mohammed-Durosinlorun A, Seguya A, Okhakhu A, Chamakhi A, Sebai A, Souadka A, Asla A, Agrawal A, Persad A, Gupta A, Elgazar A, Kulkarni A, Coates A, Bellés AC, Hadzibegovic AD, Jotic A, Kowark A, Martins A, Pineda AM, Peral A, Gollarte AS, Senent-Boza A, Camarena AIA, Castaño-Leon AM, Bravo AMM, Moro AMG, Musina AM, Tapia-Herrero AM, Kothari A, Gupta A, Raja A, Aljaiuossi A, Taha A, Majbar AM, Prodromidou A, Kanatas A, Gupte A, Zakaria AD, Balla A, Barberis A, Bondurri A, Bottari A, Costantino A, Figus A, Lauretta A, Mingoli A, Romanzi A, Sagnotta A, Scacchi A, Picchetto A, Valadez AEC, Luzzi AP, Älgå A, Fontalis A, Hecker A, Demetriades AK, Serban AM, Văcărașu AB, Cokan A, Isaza-Restrepo A, Beamish A, Schache A, Stevenson A, Yiu A, Cockbain AJ, Litvin A, Abad-Motos A, Becerra A, Ramos ÁC, Chiaradia A, Dell A, Romano A, Pascale A, Marra AA, Dimas A, Kolias A, Cerovac A, Koneru A, Tidjane A, Agbeko AE, Bajaj A, Gosain A, Allan A, Carreras-Castañer A, D'amore A, Dare A, Maffioli A, Palepa A, Paspala A, Konney A, Gatta AND, Ezanno AC, Yiallourou A, Kinnair A, Rayner A, Scafa AK, Bowan AB, Veglia A, Russo A, Maniaci A, Castaldi A, Gil-Moreno A, Maffuz-Aziz A, Meola A, Nenna A, Ferrer AP, Bonilla AR, Ramos-De La Medina A, Infante AR, Santoro A, Laganà AS, Bateman A, Michael ALR, Abozid A, Seidu AS, Lowery A, Tantraworasin A, Rasheed A, Picciariello A, Isik A, Saif A, Anjum A, Ioannidis A, Abeldaño A, Hussain A, Nathan A, Bedzhanyan A, Perfecto A, De Virgilio A, Galvan A, Sablotzki A, Böttcher A, Pellacani A, Gatti A, Ibrahimli A, Menon A, Sahni A, Mwenda AS, Choudhry A, Jayawardane A, Gupta A, Ramasamy A, Mitul AR, Bawa A, Nugur A, Rammohan A, Sachdeva A, Mehraj A, Yildirim A, Alqaseer A, Radwan A, Sallam A, Syllaios A, Tampakis A, Alwael A, Samara A, Eroglu A, Rahman A, Ulkucu A, Zaránd A, Dulskas A, Tawiah A, Zani A, Vas A, Lukosiute-Urboniene A, Adamu A, Aujayeb A, Malik AA, İplikçi A, Mahmud A, Cil AP, Makanjuola A, Akwaisah A, Galandarova A, Saracoglu A, Regan A, Barlas AM, Alhassan BAB, Mostafa B, Hamida BB, Torun BC, Abdullah B, Balagobi B, Banky B, Singh B, Alegbeleye B, Yigit B, Hajjaj BN, Burgos-Blasco B, Seeliger B, Alayande B, Alhazmi B, Enodien B, Torre B, Pérez BG, Tamayo BV, De Andrés-Asenjo B, Quintana-Villamandos B, Girgin B, Barmayehvar B, Beisenov B, Creavin B, Dunne B, Marson B, Waterson B, Martin B, Zucker B, Wong BNX, Ozmen BB, Hammond B, Mbwele B, Núñez B, Dhondt B, Gafsi B, Mcleish B, Lieske B, Tailor B, La Pira B, Picardi B, Zampogna B, Casagranda B, Festa BM, Panda B, Kirmani B, Sulaiman B, Gurung B, Zacharia B, Bette B, Ayana B, Nikolovska B, Vilaró BC, De Vega Sánchez B, Hameed BZ, Diaconescu B, Kovacevic B, Bumber B, Sakakushev B, Tadic B, Malek B, Alrayes B, Thomas B, Gális B, Gallagher B, Knowles B, Cunningham B, Daley B, Mishra B, Ashford B, Pirozzi BM, Berselli B, Martinez-Leo B, Sensi B, Nardo B, Celik B, Giray B, Abud B, Almiqlash B, Pramesh CS, Taskiran C, De Campos Prado CA, Cipolla C, Kumar C, English C, Riccetti C, Vanni C, Brasset C, Downey C, Duffy C, Chwat C, Cutmore C, Sars C, Ratto C, Pacilio CA, De La Infiesta García C, Moreno CG, Magalhães C, Prada C, Zapata CS, Senni C, Flumignan CDQ, Martinez-Perez C, Duarte CL, Garcia CSR, Anderson C, Hing C, Cullinane C, Cina C, Zabkiewicz C, Sohrabi C, Guldogan CE, Ciubotaru C, Desai C, Raut C, Demetriou C, Handford C, Okpani C, Paranjape C, Koh C, Khatri C, Parmar C, Mok CW, Caricato C, Marafante C, Echieh CP, Tan CY, Ong CS, Conso C, Jardinez C, Konrads C, Warner C, Makwe CC, Henein C, Fleming C, Roland CL, Maurus C, Nitschke C, Mittermair C, Mallmann C, Andro C, Harmston C, Kuppler C, Lotz C, Nahm C, Rowe C, Ryalino C, Wallis C, Millward CP, Anthoulakis C, Apostolou C, Chouliaras C, Kalfountzos C, Kaselas C, Vosinakis C, Okereke C, Chean CS, Barlow C, Tatar C, Clancy C, Forde C, Sharpin C, Mccarthy C, Nestor C, Warden C, Ávila CC, Massaguer C, Fang CEH, Martins CP, Guerci C, Mauriello C, Holzmeister C, Miller C, Weber C, Wiesinger CG, Kenington C, Noel C, Sue-Chue-Lam C, Adumah C, Neary C, Sen C, Fitzgerald C, Ezeme C, Nastos C, Mesina C, Bombardini C, Torregrosa C, Valdespino CP, Don CP, Wickramasinghe D, Milanesi D, Armijos D, Asiimwe D, Beswick D, Clerc D, Cox D, Doherty D, Martínez DF, Lechuga DG, Gero D, Gil-Sala D, Lindegger D, Reim D, Shaerf D, Shmukler D, Branzan D, Filipescu D, Rega D, Bernardi D, Bissacco D, Fusario D, Morezzi D, Sabella D, Zimak DM, Vinci D, Sale D, Khan DZ, Thereska D, Andreotti D, Tartaglia D, Abdulai DR, Mukherjee D, Verdi D, Idowu D, John D, Johnson D, Moro-Valdezate D, Naumann D, Omar D, Proud D, Roberts D, Guzmán DS, Watson D, Bergkvist DJ, Lumenta DB, Ferrari D, Rizzo D, Degarege D, Castillo DFC, Douglas D, Wright D, Nanjiani D, Bratus D, Altun D, Sievers D, Vaysburg D, Katechia D, Ghosh D, Azize DA, Rodrigues D, Pachajoa DAP, Hayne D, Mutter D, Raimondo D, Eskinazi D, Sasia D, Corallino D, Muduly D, Grewal D, Hadzhiev D, Peristeri D, Pournaras D, Raptis DA, Angelou D, Haidopoulos D, Magouliotis D, Moris D, Schizas D, Symeonidis D, Tsironis D, Korkolis D, Tatsis D, Thekkinkattil D, Bulian DR, Pandey D, Vatansever D, Parker D, Wiedemann D, Borselle D, Pedini D, Schweitzer D, Venskutonis D, Otokwala J, Adamu KM, Pk P, Garod M, Ellafi AAD, Zivkovic D, Jelovac D, Wijeysundera D, Mcpherson D, Ryan É, Ugwu E, Baidoo EI, Shaddad E, Memişoğlu E, Naranjo EPL, Brodkin E, Segalini E, Viglietta E, Hendriks E, Bonci EA, Sá-Marta E, Ortega EN, Gomez EGL, Joviliano EE, Clune E, Horwell E, Mains E, Vasarhelyi E, Caruana EJ, Nevins EJ, Yenli EMTA, Baili E, Lostoridis E, Morgan E, Shiban E, Latif E, Tampaki EC, Ezenwa E, Irune E, Borg E, Eisa E, Gialamas E, Parvez E, Theophilidou E, Toma EA, Arnaoutoglou E, Samadov E, Kantor E, Ulman EA, Colak E, Cassinotti E, Bannone E, Sarjanoja E, Yates E, Vincent E, Lun EWY, Cerovac E, Dif ES, Alkhalifa E, Daketsey E, Fayad EA, Sheikh E, Pontecorvi E, Cammarata E, La Corte E, Rausa E, Odai ED, Guasch E, Cano-Trigueros E, Uldry E, Ros EP, Matthews E, Donmez EE, Giorgakis E, Kapetanakis E, Stamatakis E, Bua E, Schneck E, Nachelleh EA, Ofori EO, Akin E, Gönüllü E, Kirkan EF, Çelik E, Wong E, Capozzi E, Pinotti E, Colás-Ruiz E, González E, Fekaj E, Ohazurike E, Kebede E, Erginöz E, Duran EES, Scott E, Aytac E, Albanese E, Castro EJ, Albayadi E, Kriem E, Siddig E, Otify E, El Tayeb EEABH, Hong EH, Saguil E, Belzile E, Tuyishime E, Panieri E, Martínez EG, Myriokefalitaki E, Wong EG, Samara E, Agbeno EK, Drozdov E, Tokidis E, Shah FA, Barra F, Carbone F, Ferreli F, Marino F, Martinelli F, D'acapito F, Masciello F, Bàmbina F, Issa F, Salameh FT, Kethy F, Mahmood F, Gareb F, Idrees F, Karimian F, Ashraf F, Haji F, Inayat F, Begum F, Nabil F, Rosa F, Haider F, Parray F, Calculli F, Ferracci F, Saraceno F, Coppola F, Coccolini F, Fusini F, Migliorelli F, Pecoraro F, Alconchel F, Coimbra FJF, Trivik-Barrientos F, Naegele F, Almarshad F, Agresta F, Fleming F, Mendoza-Moreno F, Brzeszczyński F, Carannante F, Wu F, Aljanadi F, Hayati F, Campo F, Sorbi F, Milana F, Takeda FR, Shekleton F, Gessler F, Recker F, Grama F, Cherbanyk F, Faponle F, Angelis F, Calabretto F, Gaino F, Toia F, Bianco F, Bussu F, Cammarata F, Castagnini F, Colombo F, Ferrara F, Fleres F, Guerrera F, Litta F, Mongelli F, Pata F, Roscio F, Mulita F, Ardura F, Tejero-Pintor FJ, Calvo FJR, Escobedo FJB, Camacho FJB, Odicino F, Schmitt F, Bloemers F, Hölzle F, Gyamfi FE, Messner F, Koh F, Cáceres F, Smolle-Juettner FM, Herman F, Ayeni F, Djedovic G, De Oliveira GP, Rodrigues G, Wagner G, Bellio G, Giarratano G, Capolupo GT, Budd G, Marom G, Poillucci G, Thiruchandran G, Nicholson G, Groot G, Hoey G, Bass GA, Sachdev G, Agarwal G, Aggarwal G, Cormio G, Mazzarella G, Perrone G, Osterhoff G, Singer G, Dejeu G, Fowler G, Garas G, Gradinariu G, Theodoropoulos G, Tzimas G, Babis G, Wong GKC, Cross GWV, Micha G, Chrysovitsiotis G, Koukoulis G, Peros G, Tsoulfas G, Kapetanios G, Karagiannidis G, Verras GI, Ekwen G, Perrotta G, Petruzzi G, Bertelli G, Calini G, Fiacchini G, Pirola GM, Dolci G, Mendiola G, Baiocchi GL, Palini GM, Prucher GM, D'andrea G, Maggiore G, Cassese G, Franceschini G, Pellino G, Saponaro G, Pattacini GC, Pantuso G, Iannella G, Bonsaana GB, Lever G, Brachini G, Giraudo G, Lisi G, Russo GI, Aprea G, Pascale G, Tomasicchio G, Sandri GBL, Armatura G, Turri G, Zaccaria G, Barugola G, Lantone G, Gasparini G, Iacob G, Sozzi G, Zancana G, Mercante G, Bianco G, Brisinda G, Consorti G, Currò G, Giannaccare G, Palomba G, Pascarella G, Rotunno G, Spriano G, Vizzielli G, Cucinella G, Sica G, Campisi G, Baiocchi G, Guerra GR, Pacheco GMF, Atis G, Augustin G, Šantak G, Chauhan GS, Branagan G, Harris G, Stewart GD, Padmore G, Kocher GJ, Di Franco G, De Jesus Labrador Hernandez G, Christodoulidis G, Neal-Smith G, Yim G, Piozzi GN, Claret G, Yanowsky-Reyes G, Dhaity GD, Cakmak GK, Mohamed G, Kucuk GO, Ancans G, Banipal GS, De Bacco Marangon G, Laporte G, Martinez-Mier G, Recinos G, V GMM, Benshetrit G, Vijgen G, Pickett G, Rodriguez HA, Shiwani H, Derilo H, Awad H, El Assaad H, Raji HO, Hardgrave H, Karakullukcu HK, Abdussalam HO, Mustafa H, Parwaiz H, Khan H, Arbab H, Naga H, Salem H, Ulgur HS, Perez-Chrzanowska H, Greenlee H, Javanmard-Emamghissi H, Lederhuber H, Osman H, Adamou H, Majid HJ, Van Goor H, Spiers HVM, Manesh HF, Mushtaq H, Aljaaly H, Hasan HB, Ahmed HTA, Martinez-Said H, Aguado HJ, Consani H, Chaplin H, Mohan H, Van Vliet H, Lohse HAS, Shah H, Claireaux H, Lule H, Juara H, Abozied H, Bayo HL, Alibrahim H, Kroon HM, Ulman H, Khan H, Yonekura H, Abou-Taleb H, Wong HYF, Carpenter H, Majd HS, Zenha H, Mayer HF, Elghadban H, Abdou H, Elfeki H, Yusefi H, Gomez-Fernandez H, Horsfall HL, Meleiro H, Sungurtekin H, Junior HFL, Moloo H, Bayhan H, Şevi̇k H, Embarek H, Hamid HKS, Pradeep IHDS, Donkin I, Ateca IV, Jafarov I, Salisu I, Abdalaal I, Garzali IU, Sall I, Adebara I, Aghadi I, Ugwu I, Zapardiel I, Reis I, Nwafor I, Fakhradiyev I, Surya IU, Robo I, Njokanma I, Iannone I, Khan I, Correia I, Königsrainer I, Seiwerth I, Linero IB, Kadiri I, Florian IA, Tzima I, Akrida I, Baloyiannis I, Gerogiannis I, Katsaros I, Tsakiridis I, Valioulis I, Negoi I, Yadev I, De Haro Jorge I, Vázquez IO, Dajti I, Russo IS, Afzal I, Wasserman I, Chukwu I, Gracia I, Oliver IM, Hughes I, Mondi I, Ncogoza I, Bsisu I, Rashid I, Balasubramanian I, Omar I, Dominguez-Rosado I, Smati I, Vokshi I, Al-Badawi IA, Saleh IA, Pilkington I, Kirac I, Trostchansky I, Gawron IM, Trebol J, Martellucci J, Andreuccetti J, Abou-Khalil J, Shah J, Manickavasagam J, De Alarcón JR, Mihanovic J, O'riordan J, Archer J, Ashcroft J, Blair J, Hamill J, Munthali J, Park J, Parry J, Ryan J, Tomlinson J, Wheeler J, Wilkins J, Balogun JA, Hodgetts JM, Vatish J, Žatecký J, Dziakova J, Martin J, Beatty JW, Stijns J, Faiz J, Ripollés-Melchor J, Mata J, Vásquez JAG, Mitra JK, Tuech JJ, Mvukiyehe JP, Fallah JM, Díaz JT, Vishnoi JR, Van Den Eynde J, Rickard J, Rolinger J, Kaplowitz J, Meyer J, Reid J, Rossaak J, Smelt J, Thomas JJ, Reyes JAS, Davies J, Luc J, Alonso JAM, Hajiioannou J, Querney J, Van Acker J, Pu JJ, Cama J, Simoes J, Cozens J, Barbosa-Breda J, Ribeiro J, De Haro J, Nigh J, Bowen J, Pollok JM, Strotmann JJ, Doerner J, Edwards J, Green J, Massoud J, Mcgrath J, Squiers J, Street J, Windsor J, Santoshi JA, Meara JG, Abebrese JT, Reilly JJ, Zabaleta J, Phillips J, Herron J, Horsnell J, Dawson J, Sheen J, Kauppila JH, Konsten J, Raurich-Leandro J, Romera JS, Nuñez J, Gass JM, Blanco J, Calvache JA, Iturralde JLF, D’addino JL, Hermosa JMG, Guillen JRO, Beristain-Hernandez JL, Sole-Sedeno JM, Vives JMM, Attwood J, Furey J, Hadaya J, Mckay J, Meilak J, Natale J, Shalhoub J, Jung J, Arthur J, Kealey J, Wright J, Moreau J, Miskovic J, Juloski J, Bauset JCC, Segura-Sampedro JJ, Cisneros JRT, Gomez-Rosado JC, Arneja J, Heider J, Fernández JD, Plata-Bello J, Villanueva J, Olaogun J, Hing JX, Košir JA, Daruwalla J, Yeung J, Wormald J, Seyi-Olajide J, Rani J, Wong KY, Hristova K, Kajal K, Algarni K, Theivendran K, Futaba K, Elsayem K, Kapur K, Bailey K, El-Boghdadly K, Ataya K, Lacorbiniere K, Shah K, Tellez KSM, Szyluk K, Rangasamy K, Iyengar K, Szabómihályová K, Atkinson K, Camargo-Parra K, Galliard K, Dickson K, Singh K, Qader K, Hasan K, Spellar K, Feeney K, Ajenifuja K, Oh KE, Okunade K, Adanu K, Bateman K, Saracoglu K, Ho KW, Enwerem K, Mishra K, Verhoeff K, Bensoltane K, Larabi K, Hamdan KH, Nadi K, Fozo K, Abdelwahab K, Al-Sayaghi K, Dajani K, Algahtany K, Abdel-Galil K, Ahmed K, Bajunaid K, Bhatti K, Sofi K, Abdulsalam K, Tamoos K, Dzhumabaev K, Samo KA, Purich K, Madhvani K, Qin KR, Underwood K, Senanayake KJ, Augestad KM, Sigamoney K, Apostolou K, Bouchagier K, Bouliaris K, Bramis K, Gousias K, Lasithiotakis K, Paraskevopoulos K, Perivoliotis K, Roditis K, Stamatis K, Stroumpoulis K, Paraskevas KI, Govindarajan KK, Šimko K, Olson KA, Khobragade K, Seah KM, Kishore K, Ayad K, Papavasiliou K, Angelou K, Paniagua LC, Czako L, Ching LVK, Rai L, Gupta L, Ismail L, Mbodi L, Dasanayake L, Schröder L, Baiyewu LA, Fortuna L, Fernandez LG, Vivancos LG, Jack L, Keçi L, Lavalle L, Leonard L, Shelmerdine L, Vaassen L, Hasan L, Lazarou L, Tzelves L, Matos L, Siragusa L, Licari L, Lima LS, Solaini L, Lichman L, Moral LT, Cabeza L, Kaplan L, Valeanu L, Kaman L, Karout L, Pieteris L, Chan L, Grüßer L, Zamora L, Catarzi L, Rampersad L, Anyanwu LJ, Cheung LK, Rodríguez LV, Andreani L, Cobianchi L, Petagna L, Howse L, Gonzalez LE, Bains L, Vohra L, Ansaloni L, Bertolaccini L, Ferrario L, Orecchia L, Tirloni L, Zanin L, Morelli L, Scaravilli L, Locatello LG, García LD, Vida L, Carbone L, Heindl LM, Bonavina L, Conti L, Marano L, Verre L, Conte LE, Boccalatte L, Tellez LGS, Loureiro L, Sánchez-Guillén L, Tallon-Aguilar L, Nakano L, Alvarez-Lozada LA, Gonzalez LAS, Flórez LJG, Capitan-Morales LC, Kowalski LP, Widmer LW, Harper L, Render L, Wheldon L, Abdur-Rahman L, Doğan L, Prusty L, Katsiaras L, Gourbault L, Siddiqui MT, Saleh M, Karthigeyan M, Rodriguez M, Chowdhury M, Nagappa M, Sultania M, Bashir M, Alam M, Elshahawy MAM, Elfiky M, Loubani M, Marei M, Mewafy M, Alali M, Nassar MA, Alobied M, Bilfaqirah M, Ahmad M, Rius M, Manangi M, Dornseifer MD, Tripathi M, S M, Sokolov M, Pigeolet M, Alonso MD, Losada M, Carretero MM, Tousidonis M, Cotovio MD, Wijeyaratne M, Boira MA, Franza M, Albdour M, Alkhatieb M, Déserts MDD, Niewiera M, Vallve-Bernal M, Kavanagh MM, Migliore M, Calabrò M, Martino MD, Reicher M, Baia M, Caricato M, Clementi M, De Zuanni M, Fiore M, Giacometti M, Inama M, Maestri M, Materazzo M, Sparavigna M, Pascale MM, Nemeth M, Serra M, Fahim MMF, Soucheiron MC, Papadoliopoulou M, Wittmann M, Sotiropoulou M, García-Conde M, Ranucci MC, Amo MDAD, Boedo MJM, Velázquez MJM, Pissaridou MK, Petersen ML, Sacras ML, Modolo MM, Caubet MM, Di Nuzzo MM, Ntalouka MP, Menna MP, Aguilera-Arevalo ML, Rela M, Capuano M, Hollyman M, Olivos M, Sacdalan MD, Raphael MC, Takkenberg M, Bortul M, Cabrera M, Castaño M, D'oria M, Giuffrida M, Laborde MM, Rodriguez-Lopez M, Trejo-Avila M, Papa MV, Ghobrial M, Kryzauskas M, Anwer M, Cheetham M, Davies M, Higgins M, Siboe M, Tarle M, Velten M, Wurm M, Süleyman M, Bauer M, O’dwyer M, Caretto M, De La Rosa-Estadella M, Fragoso M, Serra ML, Merayo M, Golet MR, Martínez-Sánchez MI, Domingo MMA, Gosselink M, Batstone M, Reichert M, Salö M, Soljic M, Zambon M, Angeles MA, Abdulkhaleq M, Abdelkarim M, Alsefri M, Iwasaki M, Shiota M, Veroux M, Molina-Corbacho M, Frasson M, Serenari M, De Pastena M, Desio M, Risaliti M, Rottoli M, Bence M, Chan M, Watson M, Wiles M, Boisson M, Berselli M, Capobianco M, Di Bartolomeo M, Fehervari M, Pacilli M, Romano M, Zizzo M, Domanin M, Montuori M, Podda M, Zago M, Dzogbefia M, Frountzas M, Thaw MH, Al-Juaifari M, Gharat M, Mohamed M, Hannan MJ, Venketeswaran M, Chisthi M, Dessalegn M, Kaplan M, Çakıcı MÇ, Ulutaş ME, Hassan M, Elsadek M, Mengesha MG, Gómez ME, Elbadawy MA, Pitcher M, Tanal M, Tokocin M, Ergenç M, Çelik MN, Bareka M, Pekcici MR, Cappuccio M, Dasa M, Dewan M, El Boghdady M, Ezeanochie M, Greenhalgh M, Jenkinson M, Kelly M, Spartalis M, Zyskowski M, Racine M, De Cillia M, Chu MJJ, Mallmann MR, Zhu MZL, Klimovskij M, Vailas M, Kisielewski M, Adamina M, Campanelli M, Carvello M, Ammendola M, Manigrasso M, Scopelliti M, White M, Collins ML, Chevallay M, Borges MF, Mayo-Yáñez M, Melo MR, Ruiz-Marín M, Eiras MAF, Cunha MF, Pertea M, Slavchev M, Davidescu M, Prieto M, Agapov M, Gahwagi M, Prats MC, Rudic M, Verbic MS, Kostusiak M, Stoleriu MG, Lucas MA, Barone M, Ahmad M, Alemu MAA, Fatima M, Ida M, Sahu M, Muhaisen M, Salem M, Emara MM, Oludara M, Sotudeh M, Kassab MB, Abdelkhalek M, Alsori M, Anwar M, El-Kassas M, Elbahnasawy M, Eldabaa M, Rabie M, Hassanin MA, Thaha MA, Ali MSM, Alhamid M, Almoshantaf MB, Keramati MR, Bafaquh M, Abuzaid M, Al-Shehari M, Alharthi M, Alkahlan M, Alwash M, Alyousef M, Amir M, Basendowah M, Deputy M, Jibreel M, Alam MS, Alsharif M, Issahalq MD, Omer MEA, Abubakar MK, Draman MR, Elnour MAE, Eltayeb M, Castillo MN, Jawad M, Raut M, Ghalleb M, Katsura M, Lebe M, Abbas M, Abdelrahman M, Shalaby M, Farhan-Alanie M, Farooq M, Musadaq M, Arshad M, Anjum MA, Usman M, Chaudhary MA, Raza MA, Karim MFSA, Chaudhary MH, Janjua MH, Khokhar MI, Malik MIK, Pirzada MT, Younis MU, Elhadi M, Suer MS, Ergenç M, Binnawara M, Emmanuel M, Abbasi M, Naimzada MD, Kulimbet M, Kusunoki M, Eugene M, Chauhan M, Shokor MA, Aljiffry M, Kalın M, Kurawa M, Dincer MB, Tolani MA, Soytas M, Yakubu M, Usman MI, Aremu M, Paranyak M, Talat N, Kausar N, Dudi-Venkata N, Bazzi N, Hasan NB, Van Wyk NN, Shaban N, Almgla N, Kandevani NY, Alzerwi N, Alvarez N, Motas N, Rincón NAR, Blencowe N, Simon N, Aghtarafi N, Ghuman NK, Sharma N, Wijekoon N, Kumar N, Hassan N, Onyemaechi N, Prijović N, Özçay N, Goel N, Segaren N, Sharma N, Kalyva N, Palacios NM, Alonso NFP, Onyeagwara N, Petrucciani N, Daddi N, Lightfoot N, Power N, Segaren N, Starr N, Dreger NM, Cillara N, Colucci N, Eardley N, Tartaglia N, Zanini N, Bacalbasa N, Campuzano N, Mouawad N, Federico NSP, Tamini N, Mariani NM, Beasley N, Adu-Aryee NA, Burlov N, Dimitrokallis N, Gouvas N, Machairas N, Memos N, Thomakos N, Tsakiridis N, Schizas N, Börner N, Theochari N, Al-Saadi N, Glass N, Horesh N, R NE, Gahlot N, Ismail N, Aljirdabi N, Maria NUH, Trabulsi N, Akeel N, Borges N, Moda N, Redondo NV, Nyarko OO, Ginghina O, Enciu O, Okere O, Ekwunife OH, Quadri O, Ogundoyin O, Tucker O, Mateo-Sierra O, Azzis O, Ojewuyi O, Habeeb O, Idowu O, Elebute O, Agboola O, Ladipo-Ajayi O, Oyinloye O, Adebola O, Ekor O, Ogundoyin O, Salamanca O, Vergara-Fernandez O, Wafi O, Aladawi O, Bahassan OM, Tammo Ö, Ozkan OF, Williams OM, Salami O, Akinajo O, Sakhov O, Gallo O, Sole OM, Milella O, Alser O, Bettar OA, Alomar O, Osman OS, Aisuodionoe-Shadrach O, Basnayake O, Bozbiyik O, Hodges O, Ojo O, Yanık Ö, Mutlu ÖPZ, Kazan O, Calavia P, García PR, Urriza PV, Lopez PR, Christidis P, Dorovinis P, Kokoropoulos P, Mourmouris P, Papatheodorou P, Garg PK, Patel P, Vassiliu P, Campennì P, De Nardi P, Bernante P, Ubiali P, Baroffio P, Pizzini P, Sapienza P, Myrelid P, Chatzikomnitsa P, Tsiantoula P, Gada P, Avella P, Cianci P, Romero P, Méndez PS, Pazmiño PAF, Coughlin P, Kirchweger P, Pessaux P, Maguire PJ, Petrone P, Cullis P, Köglberger P, Marriott P, Nankivell P, Santos-Costa P, Martins PN, Panahi P, Botelho P, Teixeira P, Escobar P, Vázquez PJG, Gribnev P, Nolte P, Agbonrofo P, Bobak P, Choong P, Elbe P, Hutchinson P, Labib P, Paal P, Pockney P, Reemst P, Szatmary P, Vaughan-Shaw PG, Alexander P, Pucher P, Stather P, Foessleitner P, Winnand P, Zehnder P, Kruse P, Matos PAW, Lapolla P, Cicerchia PM, Solli P, Di Lascio P, Zarif P, Champagne PO, Anoldo P, Bertoglio P, Fransvea P, Familiari P, Lombardi PM, Stogowski PT, Bruzzaniti P, Tripathi P, D'sa P, Salunke P, Shah PA, Punjabi PPP, Christodoulou P, Hamdan Q, Tawalbeh R, Gadelkareem R, Awad R, Callcut R, Clegg R, Choron R, Payne R, Gefen R, Costea R, Drasovean R, Mirica RM, Ravindra R, Fajardo RT, Nunes RL, Aspide R, Lombardi R, Vidya R, Elboraei R, Saaid R, Ghodke R, Gupta R, Sharma RD, Lunevicius R, Kalayarasan R, Mohan R, Singh R, Sivaprakasam R, Seenivasagam RK, Rajendram R, Radulescu RB, Goicea R, Seshadri RA, Sarı R, Nataraja R, Aslam R, Abdelemam R, Shrestha R, Bharathan R, Pellini R, Guevara R, Agarwal R, Vissapragada R, Alharmi RA, Sayyed R, Browning R, Critchley R, Mallick R, Alarabi R, Beron RI, Függer R, Othman R, Saad R, Amores RR, Colombari RC, Radivojević RC, Patrone R, Novysedlák R, Palacios Huatuco RM, Baertschiger R, Liang R, Luckwell R, Escrevente R, Rezende RF, Cruz RP, Lenzi R, Rosati R, Donovan R, Egan R, Morris R, Page R, Seglenieks R, Unsworth R, Wilkin R, Skipworth RJ, Davies RJ, Bezirci R, Talwar R, Azami R, Bohmer R, Crichton R, Fruscio R, Hooker R, Jach R, Parker R, Pillerstorff R, Sinnerton R, Stabler R, O'connell RM, Ragozzino R, Tutino R, Angelico R, Cammarata R, Colasanti R, Macchiavello R, Peltrini R, Pirrello R, Vaschetti R, Pires RE, Papalia R, Arrangoiz R, Hompes R, Mittal R, Salah R, Pinto R, Flumignan R, Callan R, Cuthbert R, Dennis R, Scaramuzzo R, Macías RM, Sánchez R, Ogu R, Ramely R, Sgarzani R, Ramli R, Hillier R, Thumbadoo R, Ooi R, Abdus-Salam R, Masri R, Hodgson R, Mathew R, Wade R, D'archi S, Khan S, Ngaserin S, Kale S, Hassan S, Merghani S, Benamar S, Muhammad S, Badran S, Elsahli S, Heta S, Hammouche S, Baeesa S, Paiella S, Eldeen STEHT, Arkani S, Mittal S, Hirji S, Tebha S, Emile S, Dbouk S, Bandyopadhyay SK, Muhammad S, Olori S, Asirifi SA, Hailu S, Ling S, Newman S, Ross S, Wanjara S, Kumar S, Seneviratne S, Tamburello S, Suarez SB, Ingallinella S, Irshaidat S, Konswa S, Mambrilla S, Nasser S, Parini S, Pitoni S, Ornaghi S, Rodrigues SC, Abdelmohsen S, Aitken S, Tian S, Badiani S, Ahmad S, Swed S, Muthu S, Lakpriya S, Alzahrani S, Mikalauskas S, Lasrado S, Satoskar S, Bawa S, Altiner S, Garcia S, Stevens S, Demir S, Ken-Amoah S, Tranca S, Ziemann S, Awad S, Atici SD, Subramaniam S, Erel S, Jiang S, Efetov S, Efremov S, Katorkin S, Valladares SC, Contreras SM, Meriç S, Zenger S, Safi S, Leventoğlu S, Elsalhawy S, Shaikh S, Sheik S, Islam S, Shamim S, Waqar SH, Ahmad S, Farid S, Seraj SS, Sundarraju S, Karandikar S, Sambhwani S, Chopra S, Chowdhury S, Laura S, Ahmed S, Wason S, Tan SJH, Fraser S, Williams S, Ghozy S, Abdelmawgoud S, Shehata S, Sharma S, Ahmed S, Al-Touny SA, Ramzanali S, Nah SA, Jansen S, Rajan S, Dindyal S, Amin S, Ahmad S, Shoukrie SIM, Karar S, Patkar S, Abdulsalam S, Lin S, Hegde S, Fiorelli S, Quaresima S, Redondo SV, Palmisano S, Ruggiero S, Balogun S, Cais S, Cole S, Federer S, Le Roux S, Ippoliti S, Meneghini S, Viola S, Manfredelli S, Novello S, Gananadha S, Mesli SN, Kale S, Tani SI, Malik S, Anastasiadou S, Boligo S, Esposito S, Valanci S, Xenaki S, Pejkova S, Bandyopadhyay S, Trungu S, Basu S, Alkhatib S, Pérez-Bertólez S, Flores SL, Donoghue S, Lunca S, Orsoo S, Potamianos S, Devarakonda S, Suresh S, Croghan SM, Turi S, Capella S, Lucchini S, Magnone S, Salizzoni S, Scabini S, Scaringi S, Cioffi SPB, Seyfried S, Degener S, Potten S, Taha-Mehlitz S, Ali S, Angamuthu S, Mcaleer S, Knight SR, White S, Mantziari S, Kykalos S, Goh SK, Chowdhury SP, Ibrahim S, Elzwai S, Bansal S, Tripathy S, Amrayev S, Anwar SL, Banerjee S, Thakar S, Saeed S, Venkatappa SK, Das S, Techapongsatorn S, Dube SK, Lee S, González-Suárez S, Henriques S, Konjevoda S, Gisbertz S, Bravo SL, Mannan S, Bukhari SI, Zafar SN, Batista S, Chin SL, Arif T, Lawal TA, Aktokmakyan TV, Osborn T, Szakmany T, Sztipits T, Triantafyllou T, Valadez TAC, Singh T, Khaliq T, Patel T, Fadalla T, Jichi T, Sammour T, Al-Shaiji T, Naggs T, Barišić T, Nikolouzakis T, Bisgin T, Perra T, Uprak TK, Dagklis T, Liakakos T, Sidiropoulos T, Adjeso TJK, Dölker T, Oung T, Aherne T, Diehl T, Pinkney T, Raymond T, Rhomberg T, Schmitz-Rixen T, Madhuri TK, Lohmann TK, Yeoh T, Zaimis T, Bright T, Vilz TO, Glowka TR, Board T, Hardcastle T, Cohnert T, Mahečić TT, William TG, Klatte T, Abbott T, Watcyn-Jones T, Mendes T, Kulis T, Sečan T, Campagnaro T, Frisoni T, Simoncini T, Violante T, Safranovs TJ, Risteski T, Pang T, Akinyemi T, Yotsov T, Laeke T, Kochiyama T, Sholadoye TT, Alekberli T, Ezomike U, Giustizieri U, Grossi U, Köksoy ÜC, Bork U, Kisser U, Ronellenfitsch U, Saeed U, Bracale U, Jayarajah U, Rauf UHA, Bumbasirevic U, Ferrer UMJ, Ahmed U, Bello UM, Jogiat U, Sadia U, Galandarov V, Narayanan V, Calu V, Bianchi V, Ciniero V, Tonini V, Silvestri V, Vijay V, Dewan V, Lohsiriwat V, Thuduvage V, Mousafeiris V, Dragisic V, Sasireka V, Santric V, Kusuma VRM, Kolli VS, Alonso V, De Simone V, Picotti V, Martínez VM, Panduro-Correa V, Kakotkin V, Angulo VP, Turrado-Rodriguez V, Krishnamoorthy V, Ban VS, Shah V, Maiola V, Giordano V, La Vaccara V, Lizzi V, Papagni V, Schiavone V, Satchithanantham V, Garcia-Virto V, Jimenez V, Kumar V, Shelat V, Bhat V, Sodhai V, Graziadei V, Kutuzov V, Stoyanov V, Oktseloglou V, Flis V, Elhassan WAF, Yang W, Soon WC, Tashkandi W, Al-Khyatt W, Mabood W, Bijou W, Wijenayake W, D W, Krawczyk W, Atkins W, Bolton W, White W, Ceelen W, Vagena X, Gozal Y, Baba YI, Subramani Y, Jansen Y, Mittal Y, Kara Y, Zwain Y, Noureldin Y, Alawneh Y, Aydin Y, Lam YH, Tang Y, Lim Y, Dean Y, Tanas Y, Su YX, Fujimoto Y, Altinel Y, Frolova Y, Oshodi Y, Fadel ZT, Zahid Z, Elahi Z, Djama Z, Zaheen Z, Jawad Z, Demetrashvili Z, Gebremeskel Z, Gudisa Z, Alyami Z, Garoufalia Z, Li Z, Zimak Z, Radin Z, Balogh ZJ. Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries. Br J Surg 2023; 110:804-817. [PMID: 37079880 PMCID: PMC10364528 DOI: 10.1093/bjs/znad092] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. METHODS This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries. RESULTS In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. CONCLUSION This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.
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Monahan M, Glasbey J, Roberts T, Jowett S, Pinkney T, Bhangu A, Morton DG, Ramos de la Medina A, Ghosh DN, Ademuyiwa AO, Ntirenganya F, Tabiri S. The costs of surgical site infection after abdominal surgery in middle income countries: Key resource use In Wound Infection (KIWI) study. J Hosp Infect 2023; 136:38-44. [PMID: 37086854 DOI: 10.1016/j.jhin.2023.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries. METHODS Centres from a randomised controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle (India, Mexico) and two lower-middle (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated versus contaminated-dirty), country and timing (inpatient versus outpatient). FINDINGS 335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases was in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery. CONCLUSION SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.
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Affiliation(s)
- Mark Monahan
- Health Economics Unit, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom.
| | - James Glasbey
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Tracy Roberts
- Health Economics Unit, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom; NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Sue Jowett
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Tom Pinkney
- Birmingham Surgical Trials Consortium, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom
| | - Aneel Bhangu
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Dion G Morton
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom; Birmingham Surgical Trials Consortium, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom
| | | | - Dhruva N Ghosh
- India Hub NIHR Global Health Research Unit on Global Surgery, Ludhiana, India; Department of Anaesthesia and Surgery, Christian Medical College, Ludhiana, India
| | - Adesoji O Ademuyiwa
- Department of Surgery, College of Medicine and Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Stephen Tabiri
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies and Tamale Teaching Hospital, Tamale, Ghana
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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, Solomi CV, Alpheus RA, Choudhrie AV, Gunny RJ, Joseph S, Malik MA, Peters NJ, Pundir N, Samujh R, Ahmed HI, Aziz G, Chowdri NA, Dar RA, Kour R, Mantoo I, Mehraj A, Parray FQ, Saqib N, Shah ZA, Wani RA, Raul S, Rautela K, Sharma R, Singh N, Vakil R, Chowdhury P, Chowdhury S, Mathai S, Nayak P, Roy B, Alvarez Villaseñor AS, Ascencio Díaz KV, Avalos Herrera VJ, Barbosa Camacho FJ, Hernández AB, Ahumada EB, Brancaccio Pérez IV, Calderón Llamas MA, Cardiel GC, Cervantes Cardona GA, Guevara GC, Perez EC, Chávez M, Chejfec Ciociano JM, Cifuentes Andrade LR, Cortés Flores AO, Cortes Torres EJ, Cueto Valadez TA, Cueto Valadez AE, Martinez EC, Barradas PD, Estrada IE, Becerril PF, Flores Cardoza JA, Orozco CF, García González LA, Reyna BG, Sánchez EG, González Bojorquez JL, Espinoza EG, Ojeda AG, González Ponce FY, Guerrero Ramírez CS, Guzmán Barba JA, Guzmán Ramírez BG, Guzmán Ruvalcaba MJ, Hérnandez Alva DA, Ibarra Camargo SA, Ibarrola Peña JC, Torres MI, Tornero JJ, Lara Pérez ZM, País RM, Mellado Tellez MP, Miranda Ackerman RC, Santana DM, Villela GM, Hinojosa RN, Escobar CN, Rodríguez IO, Flores OO, Barreiro AO, Rubio JO, Pacheco Vallejo LR, Pérez Bocanegra VH, Pérez Navarro JV, Plascencia Posada FJ, Quirarte Hernández MA, Ramirez Gonzalez LR, Reyes Elizalde EA, Romo Ascencio EV, Bravo CR, Ruiz Velasco CB, Sánchez Martínez JA, Villaseñor GS, Sandoval Pulido JI, Serrano García AG, Suárez Carreón LO, Tijerina Ávila JJ, Vega Gastelum JO, Vicencio Ramirez ML, Zarate Casas MF, Zuloaga Fernández del Valle CJ, Mata JAA, Vanegas MAC, Arias RGC, Tinajero CC, Samano FD, Zepeda FD, Barajas BVE, Banuelos GG, Calvillo MDCG, Ortiz FI, Ramirez ML, Arroyo GL, Angeles LOM, Morales Iriarte DGI, Lomeli AFM, Navarro JEO, Perez JO, Ramirez DO, Baolboa LGP, Lozano JP, Reyes GY, Castillo MN, Dominguez ACG, Mellado DH, Morales JFM, del Carmen H Namur L, Pesquera JAA, Maldonado LMP, De la Medina AR, Bozada-Gutierrez K, Casado-Zarate AF, Delano-Alonso R, Herrera-Esquivel J, Moreno-Portillo M, Trejo-Avila M, Fonseca RKC, Hernandez EEL, Quiros BC, Ramirez JAR, Ambriz-González G, Becerra Moscoso MR, Cabrera-Lozano I, Calderón-Alvarado AB, León-Frutos FJ, Villanueva-Martínez EE, Abdullahi A, Abubakar M, Aliyu MS, Awaisu M, Bakari F, Balogun AO, Bashir M, Bello A, Daniyan M, Duromola KM, Gana SG, George MD, Gimba J, Gundu I, Iji LO, Jimoh AO, Koledade AK, Lawal AT, Lawal BK, Mustapha A, Nwabuoku SE, Ogunsua OO, Okafor IF, Okorie EI, Oyelowo N, Saidu IA, Sholadoye TT, Sufyan I, Tolani MA, Tukur AM, Umar AS, Umar AM, Umaru-Sule H, Usman M, Yahya A, Yakubu A, Yusuf SA, Abdulkarim AA, Abdullahi LB, Abdullahi M, Ado KA, Aliyu NU, Anyanwu LJC, Daneji SM, Magashi MK, Mohammad MA, Muhammad AB, Muhammad SS, Muideen BA, Nwachukwu CU, Sallau SB, Sheshe AA, Soladoye A, Takai IU, Umar GI, Yahaya A, Abdulrasheed L, Adze JA, Airede LR, Aminu B, Bature SB, Bello-Tukur F, Chinyio D, Duniya SAN, Galadima MC, Hamza BK, Joshua S, Kache SA, Kagomi WY, Kene IA, Lawal J, Makama JG, Mohammed C, Mohammed-Durosinlorun AA, Nuwam D, Sale D, Sani A, Tabara S, Taingson MC, Usam E, Yakubu J, Adegoke F, Ige O, Odunafolabi TA, Okereke CE, Oladele OO, Olaleye OH, Olubayo OO, Abiola OP, Abiyere HO, Adebara IO, Adeleye GTC, Adeniyi AA, Adewara OE, Adeyemo OT, Adeyeye AA, Ariyibi AL, Awoyinka BS, Ayankunle OM, Babalola OF, Bakare A, Bakare TIB, 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, Akande O, Anyanwu N, Atobatele KM, Bakare OO, Eke G, Faboya OM, Imam ZO, Nwaenyi FC, Ogunyemi AA, Oludara MA, Omisanjo OA, Onyeka CU, Oshodi OA, Oshodi YA, Oyewole Y, Salami OS, Williams OM, Abunimye E, Ademuyiwa AO, Adeoluwa A, Adesiyakan A, Adeyeye VI, Agbulu MV, Akinajo OR, Akinboyewa DO, Alakaloko FM, Alasi IO, Amao M, Ashley-Osuzoka C, Atoyebi OA, Balogun OS, Bode CO, Busari MO, Duru NJ, Edet GB, Elebute OA, Ezenwankwo FC, Fatuga AL, Gbenga-Oke C, Ihediwa GC, Inyang ES, Jimoh AI, Kuku JO, Ladipo-Ajayi OA, Lawal AO, Makanjuola A, Makwe CC, Mgbemena CV, Nwokocha SU, Ogunjimi MA, Ohazurike EO, Ojewola RW, Badedale ME, Okeke CJ, Okunowo AA, Oladimeji AT, Olajide TO, Olanrewaju O, Olayioye O, Oluseye OO, Olutola S, Onyekachi K, Orowale AA, Osariemen E, Osinowo AO, Osunwusi B, Owie E, Oyegbola CB, Seyi-Olajide JO, Soibi-Harry AP, Timo MT, Ugwu AO, Williams EO, Duruewuru IO, Egwuonwu OA, Ekwunife OH, Emeka JJ, Modekwe VI, Nwosu CD, Obiechina SO, Obiesie AE, Okafor CI, Okonoboh TO, Okoro C, Okoye OA, Onu OA, Onyejiaka CC, Uche CF, Ugboajah JO, Ugwu JO, Ugwuanyi K, Ugwunne C, Adeleke AA, Adepiti AC, Aderounmu AA, Adesunkanmi AO, Adisa AO, Ajekwu SC, Ajenifuja OK, Alatise OI, Badmus TA, Mohammed TO, Olasehinde O, Salako AA, Sowande OA, Talabi AO, Wuraola FO, Adegoke PA, Akinloye A, Akinniyi A, Ejimogu J, Eseile IS, Ogundoyin OO, Okedare A, Olulana DI, Omotola O, Sanwo F, Adumah CC, Ajagbe AO, Akintunde OP, Asafa OQ, Awodele K, Eziyi AK, Fasanu AO, Ojewuyi OO, Ojewuyi AR, Oyedele AE, Taiwo OA, Abdullahi HI, Adewole ND, Agida TE, Ailunia EE, Aisuodionoe-Shadrach O, Akaba GO, Alfred J, Atim T, Bawa KG, Chinda JY, Daluk EB, Eniola SB, Ezenwa AO, Garba SE, Mbajiekwe N, Mshelbwala PM, Ndukwe NO, Ogolekwu IP, Ohemu AA, Olori S, Osagie OO, Sani SA, Suleiman S, Sunday H, Tabuanu NO, Umar AM, Agbonrofo PI, Arekhandia AI, Edena ME, Eghonghon RA, Enaholo JE, Ida G, Ideh SN, Iribhogbe OI, Irowa OO, Isikhuemen ME, Odutola OR, Okoduwa KO, Omorogbe SO, Oruade D, Osagie OT, Osemwegie O, Abdus-Salam RA, Adebayo SA, Ajagbe OA, Ajao AE, Ajibola G, Ayandipo OO, Egbuchulem KI, Ekwuazi HO, Elemile P, Fakoya A, Idowu OC, Irabor DO, Lawal TA, Lawal OO, Ogundoyin OO, Ojediran O, Olagunju N, Sanusi AT, Takure AO, Abdur-Rahman LO, Adebisi MO, Adeleke NA, Afolabi RT, Aremu II, Bello JO, Bello R, Lawal A, Lawal SA, Ojajuni A, Oyewale S, Raji HO, Sayomi O, Shittu A, Abhulimen V, Igwe PO, Iweha IE, John RE, Okoi N, Okoro PE, Oriji VK, Oweredaba IT, Mizero J, Mutimamwiza I, Nirere F, Niyongombwa I, Majyabere JP, Byaruhanga A, Dukuzimana R, Habiyakare JA, Nabada MG, Uwizeye M, Ruhosha M, Igiraneza J, Ingabire F, Karekezi A, Masengesho JP, Mpirimbanyi C, Mukamazera L, Mukangabo C, Niyomuremyi JP, Ntwari G, Seneza C, Umuhoza D, Habumuremyi S, Imanishimwe A, Kanyarukiko S, Mukaneza F, Mukantibaziyaremye D, Munyaneza A, Ndegamiye G, Nyirangeri P, Tubasiime R, Uwimana JC, Dusabe M, Izabiriza E, Maniraguha HL, Mpirimbanyi C, Mutuyimana J, Mwenedata O, Rwagahirima E, Zirikana J, Sibomana I, Rubanguka D, Umuhoza J, Uwayezu R, Uzikwambara L, Hirwa AD, Kabanda E, Mbonimpaye S, Mukakomite C, Muroruhirwe P, Butana H, Dusabeyezu M, Mukasine A, Utumatwishima JN, Batangana M, Bucyibaruta G, Habumuremyi S, de Dieu Haragirimana J, Imanishimwe A, Ingabire AJC, Mukanyange V, Munyaneza E, Mutabazi E, Mwungura E, Ncogoza I, Ntirenganya F, Nyirahabimana J, Nyirasebura D, Urimubabo CJ, Dusabimana A, Kanyesigye S, Munyaneza R, Shyirakera JY, Fourtounas M, Adams MA, Ede CJ, Hyman G, Mathe 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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Bhangu A, Buchwald P, Ntirenganya F. Postoperative antibiotics can be de-escalated after laparoscopic surgery for complex appendicitis. Lancet 2023; 401:323-324. [PMID: 36669518 DOI: 10.1016/s0140-6736(22)02544-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/02/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Aneel Bhangu
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TH, UK.
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital Malmö, Lund University, Lund, Sweden
| | - Faustin Ntirenganya
- Department of Surgery, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
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Ntirenganya F, Twagirumukiza JD, Bukibaruta G, Byiringiro F, Rugwizangoga B, Rulisa S. Predictors of molecular subtypes in women with breast cancer in Rwanda. rmj 2022. [DOI: 10.4314/rmj.v79i4.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION: Breast cancer (BC) constitutes a major public health problem worldwide. It remains a major scientific, clinical and societal challenge, generally in Africa and particularly in Rwanda. The purpose of this study was to determine clinical and histopathological predictors of BC molecular subtypes in Rwandan women.METHODS: A retrospective cohort study including patients with histological confirmation of BC. Using R statistical software, a regression model for multinomial responses was developed. Univariate and multivariate logistic regression analyses were used to identify independent BC molecular subtypes predictors. A two-sided p<0.05 indicated a statistically significant difference.RESULTS: Forty seven percent of cases presented with advanced stages (Stage III and IV). Postmenopausal BC (p=0.0142), absence of infertility (p=0.018) predicted Luminal A subtype with a predictive accuracy of 0.65. Age (p=0.003), postmenopausal BC (p=0.005), absence of axillar lymph nodes (p= 0.008) and poorly differentiated tumor (p=0.012) were predictors for Luminal B subtype with a predictive accuracy of 0.86. Age (p=0.045), BMI (p=0.005), rapid progression (p=0.032), tumor size T2-T3 (p<0.001) were predictors of HER2-Enriched subtype with a predictive accuracy of 0.70. Age below 40 (p=0.005), painless mass (p=0.030), nodal involvement (p=0.008), Nottingham grade 3 (p<0.001) predicted Triple Negative tumors with a predictive accuracy of 0.71.CONCLUSION: Clinical and histopathological tumor characteristics can be used to predict BC molecular subtypes with acceptable accuracy. Further studies are needed to explore the possibility of developing a scoring system for clinical decision-making, especially in settings where immunohistochemistry testing is limited.
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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, Obbeng A, Akosua A, Jeffery-Felix A, Mohammed-Durosinlorun AA, Jimoh AO, Umar AM, Umar AM, Mahajan A, Eziyi AK, Bennin A, Dasari A, Okedare A, Mathew AE, Florencia Casado-Zarate A, Calderón-Alvarado AB, Dominguez ACG, Cortés Flores AO, Dusabimana A, Kutma A, Byaruhanga A, Houndote A, Cueto Valadez AE, Alvarez Villaseñor AS, Bhangu A, Ortega Barreiro A, Mortola Lomeli AF, Luther A, Yahya A, Eseenam Agbeko A, Thomas A, Goyal A, Mkoh Dikao AS, Appiah AB, Gaou A, Bediako-Bowan AA, Ramos De la Medina A, Seidu AS, Munyaneza A, Ahounou A, Akoto-Ampaw A, Hadonou A, Alitonou A, Sambo A, Mathew AJ, Chaturvedi A, Gautham AK, Choudhrie AV, Attri AK, Kumar A, Sukumar A, Mehraj A, Shittu A, Mukasine A, Oppon-Acquah A, Kusiwaa A, Suroy A, Ezenwa AO, Takure AO, Akinniyi A, Ogunyemi AA, Makanjuola A, Dossou Yovo BB, Alhassan BAB, Hamza BK, Awoyinka BS, Koomson B, Aminu B, Abodunde Muideen B, Osunwusi B, García Reyna B, Oppong BA, Brimpong BB, Fenu BS, Ofori BA, Guzmán Ramírez BG, Nyadu BB, Shankar B, Lawal BK, Armstrong Alia B, Roy B, Kontor BE, Kovohouande B, Cakpo B, Enriquez Barajas BV, Crocco Quiros B, Kadir B, Mohammed C, Nwachukwu CU, Colunga Tinajero C, Ruiz Velasco CB, Zuloaga Fernández del Valle CJ, Noufuentes C, Solomi CV, Okunlola CK, Seneza C, Okafor CI, Nuño Escobar C, Banka C, Barimah CG, Chetana C, Nyatsambo C, Okeke CJ, Jeffrey Ede C, Nwosu CD, Victoria Mgbemena C, Onyeka CU, Gold CS, Faith Uche C, Chigoze Makwe C, Urimubabo CJ, Coompson CL, Ashley-Osuzoka C, Gbenga-Oke C, Bidemi Oyegbola C, Mukakomite C, Mpirimbanyi C, Asare C, Bode CO, Ugwunne C, Onyejiaka CC, Okoro C, Okereke CE, Mukangabo C, Sie-Broni C, Ballu C, Fuentes Orozco C, Kyeremeh C, Adumah CC, Ruelas Bravo C, Bokossa Kandokponou CM, Guerrero Ramírez CS, Teye-Topey C, Kpangon C, Chinyio D, Orozco Ramirez D, Mora Santana D, Nyirasebura D, Hérnandez Alva DA, Acquah DK, Prakash DD, Sale D, Olulana DI, Oruade D, Jayne D, Morales Iriarte DGI, Ogudi DKD, Olatola DO, Akinboyewa DO, Irabor DO, Nuwam D, Mukantibaziyaremye D, Jain D, Singla D, Garnaik DK, Singh DS, Gakpetor DA, Esssien D, Rubanguka D, Poonia DR, Ghosh D, Ahogni D, Morton D, Umuhoza D, Morel Seto D, Nepogodiev D, Enti D, Smith D, Osei-Poku D, Acheampong DO, Mellado DH, Ofosuhene D, Cortes Torres EJ, Efren Lozada E, Gómez Sánchez E, González Espinoza E, Osei E, Mensah E, Rwagahirima E, Quartson EM, Li E, Kurien EN, Bonilla Ahumada E, Kabanda E, Odame E, Izabiriza E, Hatangimana E, Osariemen E, Reyes Elizalde EA, Agbowada EA, Usam E, Sylvester Inyang E, Owie E, Ojo Williams E, Munyaneza E, Mutabazi E, Kojo Acquah E, Obiri EL, Ofori EO, Runigamugabo E, Yhoshu E, Malade E, Cervantes Perez E, Kobby E, Okwudiri Ohazurike E, Jerry Bara E, Agyemang E, Akoto E, Villanueva-Martínez EE, Mwungura E, Cueva Martinez E, Asabre E, Adjei-Acquah E, Abunimye E, Daluk EB, Daniel ER, Ike Okorie E, Ailunia EE, Abraham ES, Romo Ascencio EV, Harrison E, Kpatchassou E, Bakari F, González Ponce FY, Huda F, Abubakari F, Ntirenganya F, Ingabire F, Parray FQ, Brant F, Alakaloko FM, Diaz Samano F, Duque Zepeda F, Bello-Tukur F, Basirwa Musengo F, Dedey F, Adegoke F, Amponsah-Manu F, Mukaneza F, Chinonso Ezenwankwo F, Sanwo F, Dossou FM, Nwaenyi FC, Ibanez Ortiz F, Barbosa Camacho FJ, León-Frutos FJ, Plascencia Posada FJ, Nirere F, Owusu F, Gyamfi FE, Wuraola FO, Cervantes Guevara G, Ntwari G, Ambriz-González G, Hyman G, Umar GI, Thami G, Adeleye GTC, Limann G, Ajibola G, Ida G, Ihediwa GC, Brown GD, Bucyibaruta G, Gallardo Banuelos G, Lopez Arroyo G, Ndegamiye G, Naah G, Morgan Villela G, Edet G, Attepor GS, Akaba GO, Aziz G, Yeboah G, Mary G, Eke G, Castillo Cardiel G, Yanowsky Reyes G, Sanchez Villaseñor G, Cervantes Cardona GA, Singh G, Boateng GC, Kola H, Abdullahi HI, Olaide Raji H, Ahmed HI, Umaru-Sule H, Kaur H, Malechi H, Sunday H, Abiyere HO, Butana H, Agossou H, Samkelisiwe Nxumalo H, Maniraguha HL, Dewamon H, Yome H, Behanzin H, Ekwuazi HO, Oweredaba IT, Mohammed I, Sufyan I, Saidu IA, Abdul-Aziz IIA, Eseile IS, Ogolekwu IP, Adebara IO, Usman Takai I, Fidelis Okafor I, Kene IA, Enyinnaya Iweha I, Mutimamwiza I, Mantoo I, Duruewuru IO, Akpo I, Niyongombwa I, Brancaccio Pérez IV, Esparza Estrada I, Gundu I, Morkor Opandoh IN, Ncogoza I, Sibomana I, Bansal I, Cabrera-Lozano I, Ishola Aremu I, Gandaho I, Lawani I, Ochoa Rodríguez I, Alasi IO, Alhassan J, Mends-Odro J, Osuna Rubio J, Orozco Perez J, González Bojorquez JL, Rodriguez Ramirez JA, Glasbey J, Emeka JJ, Lawal J, Acquaye J, Alfred J, Rugendabanga J, Mizero J, Ingabire JCA, Aimable Habiyakare J, Claude Uwimana J, de Dieu Haragirimana J, Yves Shyirakera J, Utumatwishima JN, Niyomuremyi JP, Majyabere JP, Masengesho JP, Nyirahabimana J, Vishnoi JR, Kalyanapu JA, Joseph JN, Makama JG, Pizarro Lozano J, Aguilar Mata JA, Morales JFM, Vega Gastelum JO, Oyekunle Bello J, Okechukwu Ugwu J, Amoako JK, Simoes J, Zirikana J, Nzuwa Nsilu J, Adze JA, Enaholo JE, Obateru JA, Chinda JY, Akunyam J, Boakye-Yiadom J, Cook J, Quansah JIK, Chejfec Ciociano JM, Jiménez Tornero J, Herrera-Esquivel J, Flores Cardoza JA, Sánchez Martínez JA, Guzmán Barba JA, Pesquera JAA, Orozco Navarro JE, Sandoval Pulido JI, Pérez Navarro JV, Igiraneza J, Ejimogu J, Awindaogo JK, Ugboajah JO, Ashong J, Nsaful J, Arthur J, Yakubu J, Mutuyimana J, Umuhoza J, Thomas J, Ibarrola Peña JC, Tijerina Ávila JJ, Oladayo Kuku J, Gyamfi JE, Brown J, Appiah J, Attinon J, Jacob J, Gimba J, Seyi-Olajide JO, Ngaguene J, Jyoti J, Leshiini K, Boukari KA, Kumar K, Mumuni K, Quarchey KND, Sanni K, Bozada-Gutierrez K, Mandrelle K, Atobatele KM, Awodele K, Bawa KG, Duromola KM, Egbuchulem KI, Ngaaso K, Onyekachi K, Ugwuanyi K, Okoduwa KO, Ado KA, Rathod KK, Nunoo-Ghartey K, Rautela K, Kennedy KK, Ascencio Díaz KV, Boakye-Yiadom K, Onahi Iji L, Magill L, Martinez Perez Maldonado L, Pena Baolboa LG, Montano Angeles LO, Barau Abdullahi L, Ismail L, Awere-Kyere LKB, Uzikwambara L, Adam-Zakariah L, Larbi-Siaw LA, Chukwuemeka Anyanwu LJ, Etchisse L, Abdulrasheed L, Agbanda L, García González LA, Suárez Carreón LO, Cifuentes Andrade LR, Pacheco Vallejo LR, Ramirez Gonzalez LR, Aniakwo LA, Olajide Abdur-Rahman L, Abdur-Rahman LO, Namur LDCM, Mukamazera L, Airede LR, Nontonwanou MB, Amoako-Boateng MP, Rodha MS, Kawu Magashi M, Abubakar M, Yigah M, Dayie MSCJK, Victorin Agbangla M, Pathak M, Aggarwal M, Lokavarapu MJ, Talla Timo M, Isikhuemen ME, Gbassi M, Uwizeye M, Akpla M, Adjei MNM, Picciochi M, Chávez M, Fourtounas M, Quirarte Hernández MA, Zarate Casas MF, Gloriose Nabada M, Kouroumta MC, De Cristo Gonzalez Calvillo M, Trejo-Avila M, Guzmán Ruvalcaba MJ, Monahan M, Jesudason MR, Zume M, Totin M, Djeto M, Awe M, Islas Torres M, Morna MT, Oluwadamilola Adebisi M, Adams MA, Oluwatobi Busari M, Lazo Ramirez M, Taingson MC, Ruhosha M, Dery MK, Batangana M, Mellado Tellez MP, Vicencio Ramirez ML, Agyapong MM, Nortey M, Amao M, Bahrami-Hessari M, Calderón Llamas MA, Calderon Vanegas MA, Azanlerigu M, Becerra Moscoso MR, Sethoana ME, Oludara MA, Moussa Alidou M, Mohammad MA, Bashir M, Usman M, Adnan M, Alhassan MS, Aliyu MS, Singh M, Muhindo M, Dusabeyezu M, Kichu M, Castillo MN, Gureh M, Hans MA, Hollo M, Hodonou MA, Sivakumar MV, Edena ME, Abdulsalam MA, Adebisi Ogunjimi M, Dusabe M, Dokurugu MA, Galadima MC, Agbulu MV, Agbadebo M, Eunice ME, Nosipho Mathe M, Moreno-Portillo M, Awaisu M, Daniyan M, Duke George M, Malik MA, Amadu M, Pai MV, Adetola Tolani M, Abdullahi M, Moussa N, Guessou NO, Saqib N, Christian NA, Essel N, Tabuanu NO, Olagunju N, Sam NB, Akhtar N, Oyelowo N, Bisimwa Mitima N, Adewole ND, Sharma N, Anthea Nhlabathi N, Mbajiekwe N, Mishra N, Pundir N, Winkles N, Smart N, Agboadoh N, Ndukwe NO, Aperkor NT, Adu-Aryee NA, Chowdri NA, Singh N, Peters NJ, Sharma N, Agrawal N, Syam N, Duru NJ, Sentholang N, Okoi N, Anyanwu N, Rene Hounsou N, Aliyu NU, Abiola Adeleke N, Egwuonwu OA, Okoye OA, Hyginus Ekwunife O, Olanrewaju O, Osagie OO, Adeyemo OT, Oshodi OA, Olaolu Ogundoyin O, Ogundoyin OO, Babalola OF, Olasehinde O, Ajai OT, Balogun OS, Lawal OO, Olayioye O, Sayomi O, Samuel O, Mwenedata O, Oluwaseyi Bakare O, Sowande OA, Ojewuyi OO, Omisanjo OA, Akintunde OP, Abiola OP, Abiola OP, Akande O, Elebute OA, Adewara OE, Ayankunle OM, Odesanya OJ, Alatise OI, Ajenifuja OK, Ogunsua OO, Banjo OO, Ojediran O, Oladele OO, Fatudimu OS, Ajagbe OA, Idowu OC, Ladipo-Ajayi OA, Taiwo OA, Olaleye OH, Oluseye OO, Ige O, Odutola OR, Atoyebi OA, Omar O, Ayandipo OO, Omotola O, Faboya OM, Williams OM, Irowa OO, Salami OS, Onu OA, Asafa OQ, Akinajo OR, Osemwegie O, Osagie OT, Olvera Flores O, Iribhogbe OI, Aisuodionoe-Shadrach O, Gbehade O, Ojo OD, Olubayo OO, Prabhu PS, Flores Becerril P, Kumar P, Yanto P, Mukherjee P, Haque PD, Koggoh P, Igwe PO, Trinity P, Aderemi Adegoke P, Wondoh P, Domínguez Barradas P, Ogouyemi P, Boakye P, Brocklehurst P, Elemile P, Egharevba PA, Agbonrofo PI, Okoro PE, Kumassah PK, Mensah P, Munda P, Mshelbwala PM, Alexander PV, Nyirangeri P, Muroruhirwe P, Hardy P, Kwabena PW, Zechariah P, Nayak P, Dummala P, Singh P, Solanki P, Yeboah Owusu P, Mary P, Chowdhury P, Luri PT, Pareek P, Prakash P, Kumari P, Lillywhite R, Moore R, Tinuola Afolabi R, Williams R, Alpheus RA, Sharma R, Seenivasagam RK, Vakil R, Armah R, Samujh R, Chaudhary R, John RE, Gunny RJ, Wani RA, Verma R, Thind RS, Dar RA, Eghonghon RA, Acquah R, Rajappa R, Kpankpari R, Ofosu-Akromah R, Romaric Soton R, Jain R, Guinnou R, Munyaneza R, Mares País R, Delano-Alonso R, Miranda Ackerman RC, Bello R, Kour R, Guadalupe Cano Arias RG, Uwayezu R, Nájar Hinojosa R, Mittal R, Ranjan R, Goudou R, Cethorth Fonseca RK, Hussey R, Tubasiime R, Dukuzimana R, Varghese R, Boateng RA, Pswarayi R, Ojewola RW, Abdus-Salam RA, Abdus-Salam RA, Sarfo Kantanka R, Manu R, Abdul-Hafiz S, Oyewale S, Yussif S, Abolade Lawal S, Kanyarukiko S, Abeku Yusuf S, Suleiman S, Tabara S, Mbonimpaye S, Kanyesigye S, Joshua S, Tamou SB, Gupta S, Muhammad SS, Abdulai S, Olori S, Mensah S, Asirifi SA, Sani SA, Ajekwu SC, Nwokocha SU, Quaicoo S, Tsatsu SE, Philips S, Gupta S, Misra S, Kaur S, Omorogbe SO, Eniola SB, Kwarteng SM, Tobome SR, Emmanuel Hedefoun S, Adams SM, Singh S, Duniya SAN, Yahaya S, Mohammed S, Rajan S, Adekola Adebayo S, Ibarra Camargo SA, Cousens S, Hinvo S, Kapoor S, Singh S, Nindopa S, Jacob SE, Laurberg S, Chakrabortee S, Chowdhury S, Mathai S, Prasad S, Tchati SV, Habumuremyi S, Habumuremyi S, Hamadou S, Lawani S, Veetil SK, D S, D S, Sharma S, Doe S, Mathew S, Emeka Nwabuoku S, Ideh SN, Laurent Loupeda S, Tabiri S, Olutola S, Kache SA, Bature SB, Garba SE, Gana SG, Soni SC, Raul S, Kanchodu S, Daneji SM, Sallau SB, P T S, Saluja SS, Goyal S, Surendran S, Joseph S, John S, Obiechina SO, Hounsa S, Lawal TA, Badmus TA, Bakare TIB, Mohammed TO, Cueto Valadez TA, Dhar T, Agida TE, Arkorful TE, Atim T, Orewole TO, Wordui T, Okonoboh TO, Mavoha T, Hessou TK, Agyen T, Pinkney T, Olajide TO, Odunafolabi TA, Sholadoye TT, Kumar U, Kingsley Oriji V, Varsheney VK, Samuel VM, Agyekum-Gyimah VO, Ifeanyichukwu Modekwe V, Ojo V, Abhulimen V, Pérez Bocanegra VH, Avalos Herrera VJ, Etwire VK, Ibukunoluwa Adeyeye V, Kumar V, Ismavel VA, John V, Sehrawat V, Kudoh V, Kanna V, Mukanyange V, Michael V, Adobea V, Sam VD, Ghansah WW, Asman WK, Bhatti W, Kagomi WY, Mehounou Y, Mustapha Y, Oyewole Y, Edwin Y, Oshodi YA, Adofo-Asamoah Y, Ally Z, Imam ZO, Shah ZA, Lara Pérez ZM, Robertson Z. 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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Nezerwa Y, Miranda E, Velin L, Shyaka I, Mukagaju F, Busomoke F, Nsanzimana JDD, Mukeshimana M, Mushimiyimana D, Mukambasabire B, Uwimana L, Ntirenganya F, Furaha C, Riviello R, Pompermaier L. Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study. J Surg Res 2022; 278:216-222. [DOI: 10.1016/j.jss.2022.04.066] [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: 07/20/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
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Umugwaneza N, Byiringiro F, Ndahimana P, Ivang A, Nyundo M, Ntirenganya F, Gashegu J. Unusual anatomical variations of the hepatic arteries and bile ducts: What are the surgical implications. Afr Health Sci 2022; 22:697-702. [PMID: 36910391 PMCID: PMC9993316 DOI: 10.4314/ahs.v22i3.74] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Ademuyiwa AO, Adisa AO, Bach S, Bhangu A, Harrison E, Ingabire JCA, Haque PD, Ismail L, Glasbey J, Ghosh D, Kadir B, Kamarajah SK, Li E, Lillywhite R, Mann H, Martin J, Ramos de la Madina A, Moore R, Morton D, Nepogodiev D, Ntirenganya F, Pinkney T, Pockney P, Omar O, Simoes J, Smart N, Smith D, Tabiri S, Taylor E, Wilkin R. Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials. Lancet Infect Dis 2022; 22:1242-1251. [PMID: 35644158 DOI: 10.1016/s1473-3099(22)00133-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. FINDINGS Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65-1·06]; p=0·21, I2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74-1·09]; p=0·29, I2=36·4%). INTERPRETATION Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. FUNDING National Institute for Health Research (NIHR) Global Health Research Unit.
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Rickard J, Boulware DR, Guan W, Ntirenganya F, Kline S. Has There Been Exacerbation of Disparities in Antimicrobial Resistance during the SARS-Cov-2 Pandemic? Surg Infect (Larchmt) 2022; 23:613-615. [PMID: 35904537 DOI: 10.1089/sur.2022.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jennifer Rickard
- Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Division of Infectious Disease and International Medicine, Department of Medicine, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Susan Kline
- Division of Infectious Disease and International Medicine, Department of Medicine, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. Curr Trauma Rep 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Ademuyiwa AO, Adisa AO, Bhangu A, Brocklehurst P, Chakrabortee S, Ghosh D, Glasbey J, Haque PD, Hardy P, Harrison E, Ingabire JCA, Ismail L, Kadir B, Lillywhite R, Magill L, de la Medina AR, Moore R, Monahan M, Morton D, Nepogodiev D, Ntirenganya F, Omar O, Pinkney T, Smith D, Tabiri S, Winkles N. Correction: Study protocol for a cluster randomised trial of sterile glove and instrument change at the time of wound closure to reduce surgical site infection in low- and middle-income countries (CHEETAH). Trials 2022; 23:320. [PMID: 35428269 PMCID: PMC9013136 DOI: 10.1186/s13063-022-06175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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22
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Ntirenganya F, Twagirumukiza J, Bucyibaruta G, Rugwizangoga B, Rulisa S. Breast cancer heterogeneity: Comparing pre- and postmenopausal breast cancer in an African population. J Clin Sci 2022. [DOI: 10.4103/jcls.jcls_47_22] [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] [Indexed: 11/10/2022] Open
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23
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Jayaraman S, Ntirenganya F, Nkeshimana M, Rosenberg A, Dushime T, Kabagema I, Uwitonze JM, Uwitonize E, Nyinawankusi JD, Riviello R, Bagahirwa I, Williams KL, Krebs E, Maine R, Banguti P, Rulisa S, Kyamanywa P, Byiringiro JC. Building Trauma and EMS Systems Capacity in Rwanda: Lessons and Recommendations. Ann Glob Health 2021; 87:104. [PMID: 34754760 PMCID: PMC8555476 DOI: 10.5334/aogh.3324] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Sudha Jayaraman
- Virginia Commonwealth University, Department of Surgery, US
- University of Utah, Department of Surgery, US
| | | | - Menelas Nkeshimana
- University Teaching Hospital – Kigali, Department of Accident and Emergency, RW
| | | | | | - Ignace Kabagema
- Ministry of Health of Rwanda, Service d’Aide Medicale Urgente, RW
| | | | - Eric Uwitonize
- Ministry of Health of Rwanda, Service d’Aide Medicale Urgente, RW
| | | | - Robert Riviello
- Brigham and Women’s Hospital/Harvard Medical School, Department of Surgery, US
| | | | | | - Elizabeth Krebs
- Thomas Jefferson University Hospital, Department of Emergency Medicine, US
| | - Rebecca Maine
- Harborview Medical Center, University of Washington, Department of Surgery, US
| | - Paulin Banguti
- University of Rwanda, Department of Anaesthesia, Emergency Medicine and Critical Care and King Faisal Hospital, RW
| | - Stephen Rulisa
- University Teaching Hospital – Kigali, Department of Obstetrics and Gynecology, RW
- University of Rwanda College of Medicine and Health Sciences, RW
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24
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Velin L, Donatien M, Wladis A, Nkeshimana M, Riviello R, Uwitonze JM, Byiringiro JC, Ntirenganya F, Pompermaier L. Systematic media review: A novel method to assess mass-trauma epidemiology in absence of databases-A pilot-study in Rwanda. PLoS One 2021; 16:e0258446. [PMID: 34644363 PMCID: PMC8513851 DOI: 10.1371/journal.pone.0258446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Lotta Velin
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
- * E-mail:
| | | | - Andreas Wladis
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
| | | | - Robert Riviello
- Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
| | | | | | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- University Teaching Hospital in Kigali, Kigali, Rwanda
| | - Laura Pompermaier
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
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Rubagumya F, Costas-Chavarri A, Manirakiza A, Murenzi G, Uwinkindi F, Ntizimira C, Rukundo I, Mugenzi P, Rugwizangoga B, Shyirambere C, Urusaro S, Pace L, Buswell L, Ntirenganya F, Rudakemwa E, Fadelu T, Mpunga T, Shulman LN, Booth CM. State of Cancer Control in Rwanda: Past, Present, and Future Opportunities. JCO Glob Oncol 2021; 6:1171-1177. [PMID: 32701365 PMCID: PMC7392739 DOI: 10.1200/go.20.00281] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda.,University of Global Health Equity, Burera, Rwanda
| | | | | | - Gad Murenzi
- Department of Research, Rwanda Military Hospital, Kigali, Rwanda
| | | | | | - Ivan Rukundo
- Department of Radiology, Rwanda Military Hospital, Kigali, Rwanda
| | | | - Belson Rugwizangoga
- Department of Pathology, Kigali University Teaching Hospital, Kigali, Rwanda
| | | | - Sandra Urusaro
- Department of Oncology, Inshuti Mu Buzima, Kigali, Rwanda
| | - Lydia Pace
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA
| | - Lori Buswell
- Department of Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Temidayo Fadelu
- Department of Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lawrence N Shulman
- Center for Global Cancer Medicine, University of Pennsylvania, Philadelphia, PA
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26
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Miranda E, Velin L, Ntirenganya F, Riviello R, Mukagaju F, Shyaka I, Nezerwa Y, Pompermaier L. Recording Patient Data in Burn Unit Logbooks in Rwanda: Who and What Are We Missing? J Burn Care Res 2021; 42:526-532. [PMID: 33128370 PMCID: PMC8104069 DOI: 10.1093/jbcr/iraa198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.,Division of Vascular Surgery, University of Southern California, Los Angeles, CA
| | - Lotta Velin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.,Surgery and Public Health, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Faustin Ntirenganya
- Plastic Surgery Unit, Department of Surgery, University Teaching Hospital Kigali (CHUK), Kigali, Rwanda
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | | | - Ian Shyaka
- Plastic Surgery Department, Rwanda Military Hospital, Kigali, Rwanda
| | - Yves Nezerwa
- Plastic Surgery Department, Rwanda Military Hospital, Kigali, Rwanda
| | - Laura Pompermaier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.,Linköping University Hospital, Linköping, Sweden
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27
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Knight SR, Shaw CA, Pius R, Drake TM, Norman L, Ademuyiwa AO, Adisa AO, Aguilera ML, Al-Saqqa SW, Al-Slaibi I, Bhangu A, Biccard BM, Brocklehurst P, Costas-Chavarri A, Chu K, Dare A, Elhadi M, Fairfield CJ, Fitzgerald JE, Ghosh D, Glasbey J, van Berge Henegouwen MI, Ingabire JA, Kingham TP, Lapitan MC, Lawani I, Lieske B, Lilford R, Martin J, McLean KA, Moore R, Morton D, Nepogodiev D, Ntirenganya F, Pata F, Pinkney T, Qureshi AU, Ramos-De la Medina A, Riad A, Salem HK, Simões J, Spence R, Smart N, Tabiri S, Thomas H, Weiser TG, West M, Whitaker J, Harrison EM, Gjata A, Modolo MM, King S, Chan E, Nahar SN, Waterman A, Vervoort D, Lawani I, Bedada AG, De Azevedo B, Figueiredo AG, Sokolov M, Barendegere V, Ekwen G, Agarwal A, Dare A, Liu Q, Camilo Correa J, Malemo KL, Bake J, Mihanovic J, Kuncarová K, Orhalmi J, Salem H, Teras J, Kechagias A, Arnaud AP, Lindert J, Tabiri S, Kalles V, Aguilera-Arevalo ML, Recinos G, Baranyai Z, Kumar B, Neelamraju Lakshmi H, Zachariah SK, Alexander P, Kumar Venkatappa S, Pramesh C, Amandito R, Fleming C, Ansaloni L, Pata F, Pellino G, Altibi AM, Nour I, Hamdun I, Elhadi M, Ghellai AM, Venskutonis D, Poskus T, Zilinskas J, Whitaker J, Malemia P, Tew YY, Borg E, Ellul S, Ramos-De la Medina A, Wafqui FZ, Borowski DW, van Dalen AS, Wells C, Adamou H, Ademuyiwa A, Adisa A, Søreide K, Qureshi AU, Al-Slaibi I, Al Saqqa S, Alser O, Tahboub H, Segovia Lohse HA, Shu Yip S, Lapitan MC, Major P, Simões J, Sampaio Soares A, Bratu MR, Litvin A, Vardanyan A, Allen Ingabire JC, Costas-Chavarri A, Gudal A, Albati N, Juloski J, Lieske B, Rems M, Rayne S, Van Straten S, Moodley Y, Chu K, Moore R, Ortega Vázquez I, Ruiz-Tovar J, Senanayake KJ, Thalgaspitiya SPB, Omer OA, Homeida A, Cengiz Y, Clerc D, Alshaar M, Bouaziz H, Altinel Y, Doe M, Freigofer M, Teasdale E, Kabariti R, Clements JM, Knight SR, Ashfaq A, Azodo I, Wagner G, Trostchansky I, Maimbo M, Linyama D, Nina H, Zeko A, Fermani CG, Modolo MM, Villalobos S, Carballo F, Farina P, Guckenheimer S, Dickfos M, Ajmera A, Chong C, Gourlay R, Hussaini S, Lee YJ, Majid A, Martin P, Miles R, Morris OJ, Phua J, Ridley W, Saluja T, Tan RR, Teh J, Wells A, Arora B, Dollie Q, Ho D, Ma Y, Perera OM, Truong A, Dawson AC, Lim B, Pahalawatta U, Phan J, Woon-Shoo-Tong XMS, Yeoh A, Charman L, Drane A, Laura S, Lo CCW, Mozes A, Poon R, Tan HH, Wall E, Chopra P, De Giovanni J, Dhital B, Draganic B, Duller A, Gani J, Goh YK, Jeong JY, McManus B, Nagappan P, Pockney P, Rugendyke A, Sarrami M, Smith S, Wills V, Wong HV, Ye G, Zhang G, Brooker E, Feng D, Lau B, Ngai C, Birks S, Gyorki D, Otero de Pablos J, Abbosh A, Gillespie C, Mahmoud A, Kwan B, Lawson J, Warwick A, Bingham J, Cockbain AJ, Dudi-Venkata NN, Ellaby-Hall J, Finlay B, Humphries E, Pisaniello J, Pisaniello M, Salih S, Sammour T, Abd Wahab HH, De Silva A, Hayward N, Iyer K, Maddern G, Prevost GA, Annapureddy N, Settipalli KP, Yeo J, Hempenstall L, Pham L, Purcell S, Talavera C, Vaska AI, Chaggar G, Chrapko P, Cocco A, Coulter-Nile SMCJ, Ctercteko G, French J, Gong H, Gosselink M, Jegathees T, Jin I, Kalachov M, Kiefhaber K, Lee K, Luong J, Phan S, Pleass H, Veale K, Zeng Z, Au A, DeBiasio A, Deng I, Myooran J, Nair A, Stewart P, Stift A, Unger LW, Wimmer K, Ahmed N, Hasan S, Rahman S, O'Shea M, Padmore G, Peters A, Perduca P, Pulcina G, Tinton N, Buxant F, Dabin E, Garofalo G, Dossou F, Lawani I, Gnangnon FHR, Imorou Souaibou Y, Bedada AG, Motlaleselelo P, Tlhomelang O, Lima Buarque I, Mendonça Ataíde Gomes G, Vieira Barros A, Batashki I, Damianov N, Stoyanov V, Dardanov D, Maslyankov S, Petkov P, Sokolov M, Todorov G, Zhivkov E, Akisheva A, Castilla Moreno MA, Genov G, Ilieva I, Ivanov T, Karamanliev M, Khan A, Mitkov E, Yotsov T, Atanasov B, Belev N, Slavchev M, Nsengiyumva C, Jones E, Stock S, Ekwen G, Kyota S, Brown J, Mabanza K. T, Nigo Samuel L, Otuneme C, Prosper N, Umenze F, Boutros M, Caminsky N, Dumitra S, Garfinkle R, Morency D, Salama E, Banks A, Ferri L, He H, Katz A, Liberman AS, Meterissian S, Pang A, Parvez E, Agarwal A, Dare A, Hameed U, Osman F, Sequeira S, Coburn N, Dare A, Jaffer A, Karanicolas P, Mosseler M, Musselman R, Liu X, Yip CW, Garces-Otero JS, Guzman C, Sierra S, Uribe Valencia A, Cabrera Rivera PA, Camelo S, Gonzalez A, González-Orozco A, Mosquera Paz MS, Perez Rivera CJ, Gonzalez F, Isaza-Restrepo A, Nino- Torres L, Arias Madrid N, Mendoza Arango MC, Sierra S, Bake J, Tsandiraki J, Jemendžic D, Kocman B, Šuman O, Canic R, Jurišic D, Karakas I, Krizanovic Rupcic A, Pitlovic V, Samardžic J, Kopljar M, Bacic I, Domini E, Karlo R, Mihanovic J, Miljanic D, Simic A, Ahmed M, Al Nassrallah M, Altaf R, Amjad T, Eltoum R, Haidar H, Hassan A, Khalil O, Qasem M, Ramesh R, Sajith G, Wisal M, Žatecký J, Bujda M, Jirankova K, Paclik A, Abdallah A, Abdulgawad Almogy M, Ayman El-sawy E, ElFayoumy AM, Elghareeb N, Esmat NA, Fadel A, Habater A, Hamdy H, Hefni A, Kamal M, Mohamed Abobakr N, Sayed A, Shaker N, Taha E, Tharwat H, Zakaria O, Abdelmotaleb I, Al-Dhufri A, Al-Himyari HS, El sheikh E, Eldmaty A, Elkhalawy A, M.Elkhashen A, Magdy K, Mostafa S, Sadia HD, Saleh MM, Samir D, Yahia Mohamed Ali M, A. Nassar M, Abdelhady S, Abdelrazek A, Abdelsalam I, El-Sawy A, Essam E, Gadelkarim M, Ghaly K, Hassabalnaby M, Masarani R, Mohamed Shaaban N, Sabry A, Salem M, Soliman NA, Zahran D, Abou El.soud MR, Badr ET, Borham H, Elmeslemany N, Elsayed M, Elsherif F, Eslam S, Gaber G, Ibrahim S, Kamh Y, Mahmoud A, Mohamed SG, Morshedy E, Omar C, Salem Soliman F, Abdelkawy S, Abdelmohsen N, Abdelshakour M, Dahy A, Gamal N, Gamal M, Hasan A, Hetta H, Mousa N, Omar M, Rabie S, Saad M, Saleh B, Sayed Mohamed M, Shawqi M, Abdelhady Mousa H, Alnoury M, Elbealawy M, Elshafey A, Essam Ibrahim El Desouki Muhammad Ahmed M, Ghonaim M, Hgag F, Ibrahim M, Morsy M, Reda Loaloa M, Refaat A, Samir H, Shahien F, Sobhy M, Sroor F, Abdellatif E, Adel M, Afifi AA, Afifi E, Antaky M, Dawoud A, El Zoghby N, El-remaily A, Elzanfaly AA, Gadallah A, Gamal FA, Hashem O, Medhat Youssef S, Muhammad Attyah A, Munir M, Shazly O, Taha E, Wilson K, Adel S, Ali A, Eid E, Elhelow E, Elmahdy M, Elshatby B, Hossam el-din Zakaria A, Hossny A, Ibrahim E, M.Yonis A, Metwalli M, Yousry B, Zid E, A Yacoub M, Abdelhakim A, Abouelsoad N, Alkhatib M, Ashraf A, Ashraf A, Elazab Y, Elfanty M, Elkabir O, Elsayed M, Elshimy A, Elsobky H, Eskander J, Gad A, Hamsho W, Khaled Abdelwahed N, Magdy M, Moharam D, Osama A, Ramadan S, Roum R, Sayed T, Shehada T, Zidan AM, Abbas K, Ali A, Attia M, Balata M, El Nakeeb A, Elewaily MIE, Elfallal A, Elfeki H, Elkhadragy A, Emile S, Ezzat H, Hosni H, Mansour I, Omar W, Othman G, Sadek K, Shalaby M, Shehab-Eldeen N, Anas khalifa R, Badr H, Eldeep M, Eldeep A, Eldoseuky mohammed A, Khallaf S, Magdy Hegazy E, Mahmoud R, Mikhail P, Morsi M, Mowafy S, Raafat D, Safy A, Sera M, Sera AS, AbdAllah MSM, Abdelkader M, Abdou AO, Ahmed A, Gaafar S, Ibrahim negm F, Lapic M, Maher A, Mahmoud H, Mostafa A, Samir M, Samy F, Semeda N, Shalaby HI, El-taweel A, Galal Elnagar A, Hemidan AG, Hussein M, Kandil A, Moawad M, Nasser Hamamah AA, Soliman M, Abdelkhalek M, Abdelmaksoud Tawakel N, Abdelwahed AM, Abdou A, Atallah K, Elsherbeny MY, Emara E, Hamdy M, Hamdy O, Haron A, Ismail S, Metwally IH, Mohamed Hamed Elgaml N, Nassar A, Refky B, Sadek M, Saleh M, Yunes A, Zakaria M, Zuhdy M, Fayed N, Mohammed MMH, Kütner S, Melnik P, Seire I, Teras J, Ümarik T, Ainoa E, Eerola V, Koppatz H, Koskenvuo L, Sallinen V, Takala S, Katunin J, Kechagias A, Turunen A, Christou N, Mathonnet M, Lavoue V, Nyangoh Timoh K, Soulabaille L, Lesourd R, Merdrignac A, Sulpice L, André B, Chantalat E, Vaysse C, Dousset B, Gaujoux S, Martin G, Clonda O, Juodis D, Kienle K, Mravik A, Palmer S, Szabadhegyi G, Agbeko AE, Gyabaah S, Gyamfi FE, Naabo N, Owusu senior A, Yorke J, Owusu F, Abantanga F, Anyomih TTK, Muntaka AJM, Owusu Abem E, Sheriff M, Tabiri S, Wondoh PM, Balalis D, Korkolis D, Gkiokas G, Pantiora E, Theodosopoulos T, Ioannidis A, Konstantinidis K, Konstantinidou S, Machairas N, Paspala A, Prodromidou A, Chouliaras C, Papadopoulos K, Baloyiannis I, Mamaloudis I, Tzovaras G, Akrida I, Argentou MI, Germanos S, Iliopoulos E, Maroulis I, Skroubis G, Theofanis G, Chatzakis C, Ioannidis O, Loutzidou L, Kalles V, Karathanasis P, Michalopoulos N, Theodoropoulos C, Theodorou D, Triantafyllou T, Garoufalia Z, Hasemaki N, Kontos M, Kouraklis G, Kykalos S, Liakakos T, Mpaili E, Papalampros A, Schizas D, Syllaios A, Tampaki EC, Tsimpoukelis A, Antonopoulou MI, Deskou E, Manatakis DK, Papageorgiou D, Zoulamoglou M, Anthoulakis C, Margaritis M, Nikoloudis N, Campo V, Ceballos A, Flores MA, Giron W, Ko D, Martinez G, Recinos G, Rivera Lara V, Rueda N, Sanchez A, Tejeda Garrido JCG, Aguilera-Arevalo ML, Alvarez Rivera AE, Bamaca Ixcajoc EB, Barreda Zelaya LE, Chacòn-Herrera P, Corea Ruiz LM, Echeverria-Davila G, Garcia M, García D, Gutiérrez Mayen EF, José N, Mazariegos N, Méndez D, Paniagua Espinoza M, Baranyai Z, Bardos D, Benke M, Illes K, Kokas BA, Szabó R, Appukuttan A, Asok A, D.k V, Malik K, Ravishankaran P, Tapkire R, Moorthy G, Abraham J, Muthuvel R, Alapatt J, Kattepur A, Pareekutty N, Garod M, Harris C, Wanniang C, Gupta A, Nehra D, Parshad S, Acharya R, Badwe R, Bhandare M, Jain U, Kirti K, Nair N, Shrikhande S, Thakkar P, Anandan P, C S A, Holenarasipur Narasannaiah A, Jagarlamudi T, Kumar Venkatappa S, M R R, Manangi M, Raghavendra A, Rao KS, S V, Sajjan V, Shenoy A, Shivashankar Chikkanayakanahalli S, Tharanath K, V S, Adidharma P, Agarwal R, Amandito R, Anggita Gultom P, Arifin GR, Billy M, Elfizri Z, Fahira A, Felicia D, Gunardi TH, Johanna N, Nugrahadi NR, Panigoro SS, Rahmayanti S, Sihotang RC, Brata SY, Winoto H, Barati N, Karami M, Khorshidi H, Naderifar H, Abdulla MA, Coleman M, Doherty RJ, Hannon R, Murphy B, Stakelum A, Winter D, Aljohmani L, Farnan R, Seldon Y, Tan T, Varghese S, Alherz M, Ather M, Bajilan M, Graziadei V, Pilkington I, Quidwai O, Ridgway P, Shiwani H, Tahir AAR, Blunnie E, Burke D, Kennedy N, Macdonagh K, O'Neill M, Rooney S, Falco G, Ferrari G, Mele S, Nita GE, Ugoletti L, Zizzo M, Confalonieri G, Pesenti G, Tagliabue F, Baronio G, Ongaro D, Pata G, Compagnoni B, Salvadori R, Taglietti L, D'Alessandro N, Di Lascio P, Pascale G, Bortolasi L, Campagnaro T, Carlini M, Lisi G, Lombardi D, Pedrazzani C, Spoletini D, Turri G, Violi P, Altomare DF, Aquilino F, Musa N, Papagni V, Picciariello A, Vincenti L, Andreotti D, Occhionorelli S, Tondo M, Basso SMM, Cirelli R, Maino MEM, Piozzi GN, Picone E, Scaramuzzo R, Sinibaldi G, Amendola A, Anastasio L, Bucci L, Caruso E, Castaldi A, Di Maso S, Dinuzzi VP, Esposito G, Gaudiello M, Giglio MC, Greco PA, Luglio G, Manfreda A, Marra E, Mastella F, Pagano G, Peltrini R, Pepe V, Sacco M, Sollazzo V, Spiezio G, Cianchetti E, Menduni N, Carvello MM, Di Candido F, Spinelli A, Corsi F, Sorrentino L, Marino F, Asti ELG, Bonavina L, Rausa E, Asta M, Belli A, Bianco F, Cervone C, Delrio P, Falato A, Fares Bucci A, Guarino R, Pace U, Rega D, De Luca E, Gallo G, Sammarco G, Sena G, Vescio G, Santandrea L, Ugolini G, Zattoni D, Chetta N, Logrieco G, Vanella S, Garulli G, Zanini N, Bondurri A, Cammarata F, Colombo F, Foschi D, Lamperti GMB, Maffioli A, Sampietro GM, Yakushkina A, Zaffaroni G, Ansaloni L, Cicuttin E, Sibilla MG, Impellizzeri H, Inama M, Moretto G, Mochet S, Ponte E, Usai A, Mancini S, Sagnotta A, Solinas L, Bolzonaro E, Tamini N, Curletti G, Galleano R, Malerba M, Campanella S, Cocorullo G, Colli F, De Marco P, Falco N, Fontana T, Kamdem Mambou LJ, La Brocca A, Licari L, Randisi B, Rizzo G, Rotolo G, Salamone G, Tutino R, Venturelli P, Malabarba S, Sgrò A, Vella I, Cirillo B, Crocetti D, De Toma G, Lapolla P, Mingoli A, Sapienza P, Belvedere A, Bianchini S, Binetti M, Birindelli A, Tonini V, Podda M, Pulighe F, De Rosa M, Bono L, Borghi F, Geretto P, Giuffrida MC, Lauro C, Marano A, Pellegrino L, Salusso P, Sasia D, Campanelli M, Realis Luc A, Trompetto M, Cardia R, Cillara N, Giordano AN, Costanzo A, Giovilli MA, Turati L, Canonico S, Pellino G, Sciaudone G, Selvaggi F, Selvaggi L, Albsoul N, AlBsoul A, Alkhatib AA, Alsallaq O, Amarin JZ, Ayoub R, Bsisu I, El Muhtaseb MS, Jabaiti M, Melhem J, Nour I, Qwaider YZ, Salameh MH, Suleihat A, Suradi HH, Alammarin M, Aljaafreh A, Bani hani M, Bani hani Z, Bani Hani F, Fahmawee T, Hamouri S, Katanani C, Tawalbeh R, Tawalbeh T, Zawahrah H, Abou Chaar MK, Abusalem L, Al-Masri M, Al-Najjar H, Barghuthi L, Ahmed Z, Maulana A, Ngotho O, Kamau C, Stanley Mwenda A, Bosire F, Mwachiro E, Parker R, Simel I, Sylvester K, Althini AAM, Elbarouni S, Elbeshina AE, Gwea A, Malek A, Masoud Farag WA, Abdalei A, Abdel Malik AB, Abo-khammash A, Abuhlaiga M, Adnan N, Albaggar M, Alfitory A, Aljanfi A, Almuzghi F, Altumei Z, Alzabti F, Ashoushan H, Assalhi M, Azzubia J, Bnhameida S, Delhen M, Elshafei H, Elteir H, Esbaga F, Gobbi AA, Hamouda F, Hilan H, Ismail R, Jebran F, Kasbour M, Maderi G, Mohammad S, Mohammed B, Murtadi H, Mustafa H, Rajab M, Trenba S, Wafaa M, Al Sagheir E, Almigheerbi A, Alzahaf A, Bahroun SG, Ben Dallah N, Elshaibani M, Eswaye H, Karar M, Omar S, Younes E, Younes M, Zreeg D, Abujamra S, Ashour F, Elgammudi M, Omar F. Aljadidi W, Saddouh E, Sharif R, Alabuzidi A, Alwerfally A, Aribi S, Bibas F, Elfaituri T, Elhajjaji Y, Khaled A, Khalil W, Layas T, Soula E, Tarek A, Abu hallalah MFK, Abujamra S, Ahmed HA, Alsharef T, Ben Saoud AA, El Gharmoul T, Elhadi A, Elrais S, Shebani A, Zarti H, Zeiton A, Ambrazevicius M, Kaselis N, Stakyte M, Aliosin O, Cizauskaite A, Dailidenas S, Eismontas V, Kybransiene M, Nutautiene V, Samalavicius N, Simcikas D, Slepavicius A, Tamosiunas A, Ubartas N, Zeromskas P, Bradulskis S, Dainius E, Juocas J, Kubiliute E, Kutkevicius J, Opolskis A, Parseliunas A, Subocius A, Venskutonis D, Virbickaite E, Zuikyte D, Bogusevicius A, Buzaite K, Cepuliene D, Cesleviciene I, Cesna V, Gribauskaite J, Ignatavicius P, Jokubauskas M, Liugailaite M, Margelis E, Mazelyte R, Pankratjevaite L, Pažusis M, Rackeviciute A, Saladyte J, Škimelyte M, Šlenfuktas V, Sudeikyte M, Tamelis A, Vanagas T, Žumbakys Ž, Atkociunas A, Dulskas A, Kuliavas J, Birutis J, Paškevicius S, Šatkauskas M, Danys D, Jakubauskas M, Jakubauskiene L, Kryzauskas M, Lipnickas V, Makunaite G, Rasoaherinomenjanahary F, Rasolofonarivo H, Samison LH, Banda B, Malemia P, Msosa V, Ahmad Izzuddin AI, Das A, Gan YY, Shong Sheng T, Siaw JY, Ab Rahim MF, Abang Jamari DZH, Che Husin N, Kamarulzaman MY, Lim YP, Mohamed Kamil NA, Mohd Hassan MR, Mohd Sahid S, Mustafa J, Ng EHB, Wan Khazim WK, Chang Ern N, Lingeshan P, Sulaiman SE, Ang SE, Bin Mohamad Sithik MN, Cheong YJ, Deva Tata M, Jia Xian L, Kadravello A, Koh IE, Ng LY, Ng We Yong YJ, Palayan K, Sam CX, Siow Jin P, Tan Ern Hwei J, Tang Y, Ter AZ, Wong MPK, Zakaria AD, Zakaria Z, Henry F, Kalaiselvan T, Abd Karim MFS, Abdul Aziz MR, Abdul Aziz N, Khong TL, Lau PC, Lim HC, Roslani AC, Seak JCK, Wong SW, Wong LF, Yeen Chin L, Anyanwu MC, Borg E, Busuttil Z, Calleja T, Chircop KL, Cutajar R, Dimech AM, Ellul S, Galea J, Gascon Perai K, Gatt R, Kelman L, Micallef E, Nwolu F, Sammut K, Thompson J, Warwicker S, Zammit M, Cordera F, Cruz González E, Sánchez-García J, Barbosa Camacho FJ, Barrera López FJ, Zuloaga Fernandez del Valle CJ, Acosta E, González Espinoza IR, Moreno P, Cortes-Flores AO, Fuentes Orozco C, Gonzalez Ojeda A, Corro Díaz González S, Martinez L, Ramos-De la Medina A, Mosqueda Amador B, Novoa A, Olazo Espejo DA, Jimenez A, Lopez Rosales F, Vanoye EG, Garcia Gonzalez LA, Miranda-Ackerman RC, Solano-Genesta M, Alvarez-Cano A, Romero-Garza HH, Medina-Franco H, Mejía-Fernández L, Salgado-Nesme N, Vergara-Fernandez O, Gutiérrez-Mota GM, Hernandez Vera FX, Llantada Lopez A, Morgan Villela G, Ramirez Padilla FDJ, Tapia Marin W, Martínez Maldonado M, Sánchez Suárez R, Troche JM, Benyaiche C, Outani O, Amine S, Benkabbou A, Majbar AM, Mohsine R, Rafik A, Oung T, Tin MM, Borowski DW, Plarre P, Borowski DW, Plarre P, Alberga A, Sluiter N, Tuynman J, Blok R, Cömert D, Hompes R, Kalff M, Stellingwerf ME, Tanis P, van Berge Henegouwen M, van Praag EM, Wisselink D, Gerhards M, Lopes Cardozo J, Westerduin E, de Jonge J, van Geloven A, van Schilt K, den Boer F, Stoots S, Vlek S, Adams J, Al-Busaidi IS, Budd G, Choi SI, Chu MJJ, Ganugapati A, McKinstry L, Pascoe R, Richards S, Rosser K, Stevenson A, White R, Farik S, Kwun J, Murad A, Cowan S, Hall T, Hayton M, Malam Sani L, Oumarou Garba S, Adamou H, Amadou Magagi I, Habou O, Aliyu H, Daniyan M, Sholadoye TT, Abdullahi L, Anyanwu LJ, Mohammad Mohammad A, Muhammad AB, Sheshe AA, Suleiman I, Adesina A, Awolowo A, Onuoha C, Salami O, Taiwo O, Taiwo A, Kache S, Makama JG, Sale D, Abiola O, Ajao A, Ajiboye A, Etonyeaku A, Olaogun J, Adebanjo A, Adesanya O, Afolayan MO, Balogun O, Makanjuola A, Nwokocha S, Ojewola RW, Olajide TO, Aderounmu A, Adesunkanmi AR, Adisa A, Agbakwuru A, Akeem Aderogba A, Alatise OI, Arowolo O, Lawal O, Mohammed T, Ndegbu C, Olasehinde O, Wuraola F, Akinkuolie A, Etonyeaku A, Mosanya A, Ayandipo O, Elemile P, Lawal TA, Ali SANI S, Garba S, Hauwa SANI R, Olori S, Onyebuashi H, Umoke I, Adenuga A, Adeyeye A, Habeeb O, Lawal B, Nasir A, Aahlin EK, Kjønås D, Myrseth E, Abbasy J, Alvi A, Saleem O, Afzal A, Nazir A, Farooq M, Liaqat A, Naqi SA, Raza A, Sarfraz M, Sarwar M, Banglani M, Munir A, Sehrish R, Ayub B, Sayyed R, Altaf A, Ayub S, Qureshi AU, Saeed K, Syed B, Akbar SA, Anwer AW, Khan RN, Khan AI, Khattak S, Mohtasham S, Parvaiz MA, Syed AA, Ansari AB, Shahzad N, Khaliq T, Rashid I, Waqar SH, Abu Al-saleem H, Abu Alqumboz A, Alqadi M, Amro A, Assa R, Awesat E, Ayyad R, Hammad M, Haymony A, Hijazi B, Hmeidat B, Lahaseh R, Qawasmi A, Rajabi A, Shehada M, Shkokani S, Yaghi Y, Yaghi N, AlZohour M, Farid M, Habes YM, Juba W, Nubani Y, Rabee A, Sa'deh M, Abed S, Al basos I, Alswerki M, Ashour D, Awad I, Diab S, El Jamassi A, El-Kahlout S, Elhout S, Hajjaj ANK, Hasanain D, Nabil hajjaj B, Obaid M, Saikaly E, Salhi A, Al-Tammam H, Almasri M, Baniowda M, Beshtawi D, Horoub A, Misk R, Mohammad B, Qasrawi R, Sholi T, Abu-Nimeh S, Abu-srour A, Abukhalaf SA, Adawi S, Alsalameh B, Ayesh K, Elqadi M, Hammouri A, Karim Mustafa F, Marzouqa N, Melhem S, Miqdad D, Mohamad B, Rawhi M, Abu Ahammala AB, Abu Ataya A, Abu Jayyab I, Al-Shwaikh S, Alagha O, Alasttal M, Awadallah H, Elblbessy M, Fares J, Jarbou A, Mahfouz I, Albahnasawi MA, Abo mahadi A, Abuelhatal H, Abuelqomboz A, Almoqayyad A, Alwali A, Balaawi R, Hamouda M, Humeid M, Jedyan A, Mahmoud Abu hamam T, Matar G, Salem A, Samra T, Shaheen N, Shihada K, A.Nemer A, Abu Al Amrain M, Abu Alamrain A, Abu Jamie N, Abu-Rous MR, Alfarra N, AlTaweel M, Alwhaidi N, Hamed R, Saqqa B, Shaheen A, Aljaber D, Aljaberi L, Alwaheidi M, Jawaada A, Khaldi H, Qahoush R, Qari J, Saadeh R, Salim A, Yacoub A, Abbas A, Abu shua`ib R, Abu Zainah B, AbuSirrees M, Babaa B, Barhoush O, Belal qadomi A, Daraghmeh L, Haji R, Khatatbeh A, Khatib L, Qarariah S, Quzmar Y, Safadi K, Salameh R, Hassan M, Herzallah S, Massad L, Nazzal A, Nazzal R, Escobar D, Machain V GM, Rodriguez Gonzalez A, Chachaima Mar JE, Chinchihualpa Paredes NO, Cuba V, Lopez W, Niquen Jimenez MM, Sanchez Bartra NA, Sapallanay Ojeda O, Sequeiros D, Toscano Pacheco A, Vergara M, Abarca S, Alcorta R, Borda-Luque G, Eusebio Zegarra IE, Luján López C, Marrufo M, Mogrovejo C, Nomura A, Rodríguez Angeles Y, Vidal Meza MR, Zavala G, Castillo Arrascue JN, Hidrogo Cabrera JC, Larrea vera JJM, Osorio M, Ylatoma Díaz EA, Fontanilla MA, Fuentes JR, Salazar AL, Dominguez G, Lopez MP, Macalindong S, Onglao MA, Ramirez A, Sacdalan MD, Tampo MM, Uy GL, Mangahas J, Yabut K, Cañete JP, Cansana BE, Castro EJ, Lipana MK, Roxas MF, Zara VJ, Chrol M, Franczak P, Orlowski M, Budzynski P, Budzynski A, Bury P, Czerwinska A, Dworak J, Dziedzic J, Kisielewski M, Kulawik J, Lasek A, Major P, Malczak P, Migaczewski M, Pedziwiatr M, Pisarska M, Radkowiak D, Rubinkiewicz M, Rzepa A, Skoczylas T, Stanek M, Truszkiewicz K, Wierdak M, Winiarski M, Zarzycki P, Zub-Pokrowiecka A, Kowalewski P, Roszkowski R, Waledziak M, Tomé M, Patrocinio S, Guerreiro I, Almeida F, de Sousa X, Monteiro N, Costa Santos MT, de Oliveira D, Lopes Serra M, Morgado D, Neves C, Oliveira AC, Pimentel A, Silva S, Carvalho M, Carvalho L, Magalhães J, Matos L, Monteiro T, Ramos C, Santos V, Barbosa J, Costa-Maia J, Devezas V, Fareleira A, Fernandes C, Gonçalves D, Mora H, Morais M, Silva de Sousa F, Catarino Santos S, Logrado A, Tojal A, Amorim E, Cunha MF, Fazenda A, Melo Neves JP, Sampaio da Nóvoa Gomes Miguel II, Veiga D, Azevedo J, Cardoso Louro H, Leite M, Azevedo J, Bairos Menezes M, Gama B, Brito D, Cruz Martins MC, Graça e Magalhães A, Longras AC, Lourenço R, Matos D, Castro L, Policarpo F, Romano J, Leite M, Monteiro C, Pinto D, Duarte M, Fortuna Martins S, Oliveira M, Galvão D, Martins L, Silva A, Taranu V, Vieira B, Neves J, Oliveira S, Ribeiro H, Cinza M, Felix R, Machado A, Oliveira J, Patrício J, Pedroso de Lima R, Pereira M, Rocha Melo M, Velez C, Abreu da Silva A, Claro M, Costa Santos D, Ferreira A, Capote H, Rosado D, Taré F, Nogueira O, Ângelo M, Baiao JM, Guimarães A, Marques J, Nico Albano M, Silva M, Valente da Costa A, Vieira Caroço T, Almeida Braga S, Capunge I, Fragoso M, Guimarães J, Pinto B, Ribeiro J, Angel M, Fialho G, Guerrero M, Campos Costa F, Cardoso D, Cardoso V, Alves M, Estalagem I, Louro T, Marques C, Martelo R, Morgado M, Canotilho R, Correia AM, Martins P, Peyroteo M, Gomes J, Monteiro R, Romano M, Alves DM, Peixoto R, Quintela C, Jervis MJ, Melo D, Pacheco A, Paixão V, Pedro V, Pimenta J, Pimenta de Castro J, Rocha A, Beuran M, Bratu MR, Ciubotaru C, Diaconescu B, Hostiuc S, Negoi I, Stoica B, NA NA, Anokhin E, Kuznetsov G, Oganezov G, Paramzin F, Romanova E, Rutkovskii V, Rutkovskii V, Shushval M, Zabiyaka M, Dzhumabaev K, Ivanov V, Mamedli Z, Achkasov S, Balkarov A, Nabiev E, Nagudov M, Rybakov E, Saifutdinova K, Sushkov O, Vardanyan A, Costas-Chavarri A, Joseph L, Ndayishimiye I, Allen Ingabire JC, Faustin N, Mutabazi AZ, Mvukiyehe JP, Nsengimana VJ, Uwakunda C, Abbas MM, Akeel N, Aljiffry M, Awaji K, Farsi A, Jamjoum G, Khoja A, Maghrabi A, Malibary N, Nassif M, Saleem A, Sultan A, Tashkandi W, Tashkandi H, Trabulsi N, Ba MB, Diallo AC, Ndong A, Cuk V, Jankovic U, Juloski J, Koh SZ, Koh F, Lee KC, Lee KY, Lee S, Leong WQ, Lieske B, Lui SA, Prakash P, Grosek J, Norcic G, Tomazic A, Fitchat N, Jaich R, Wineberg D, Koto MZ, Baiocchi D, Clarke D, Steenkamp CJ, Van Straten S, Bannister S, Boutall A, Chinnery G, Coccia A, Dell A, Karjiker P, Kloppers C, Loxton N, Mabogoane T, Malherbe F, Panieri E, Rayamajhi S, Spence R, van Wyngaard T, Warden C, Madiba TE, Moodley Y, Pillay N, Brooks S, Kruger C, Van Der Merwe LH, Gool F, Kariem M, Bougard H, Chu K, Kariem N, Noor F, Pillay R, Steynfaardt L, González González L, Marín Santos JM, Martín-Borregón P, Martínez Caballero J, Nevado García C, Rodriguez Fraga P, De Castro Parga G, Fernández Veiga MP, Garrido López L, Infante Pino H, Lages Cal I, López Otero M, Nogueira Sixto M, Paniagua García Señorans M, Rodríguez Fernández L, Ruano Poblador A, Rufo Crespo E, Sanchez-Santos R, Vigorita V, Alonso Batanero E, Asnel D, Cifrian Canales I, Contreras Saiz E, De Santiago Alvarez I, Díaz Vico T, Fernandez Arias S, Fernández Martínez D, García Bernardo C, García Flórez LJ, Garcia Gutierrez C, García Munar M, Márquez Zorrilla Molina CA, Merayo M, Michi Campos JL, Moreno Gijon M, Otero-Diez JL, Rodicio Miravalles JL, Solar-Garcia L, Suárez Sánchez A, Truan N, Alejandre Villalobos C, Caballero Díaz Y, Jimenez M, Montesdeoca D, Navarro-Sánchez A, Vega V, Beltrán de Heredia J, Gómez Z, Jezieniecki C, Legido Morán AP, Montes-Manrique M, Rodriguez-Lopez M, Ruiz Soriano M, Trujillo Díaz J, Vazquez Fernandez A, Argudo N, Pera M, Torrent Jansà L, García Domínguez M, Goded I, Roldón Golet M, Talal El-Abur I, Utrilla Fornals A, Zambrana Campos V, Aguilar Martinez MDM, Bosch M, García-Catalá L, Sánchez-Guillén L, Artigau E, Gomez Romeu N, Julià Bergkvist D, Espina Perez B, Morató O, Olona C, Diéguez B, Forero-Torres A, Losada M, Gomez-Abril S, Gonzálvez P, Martinez R, Navarro Martínez S, Payá-Llorente C, Pérez Rubio Á, Santarrufina Martinez S, Sebastián Tomás JC, Trullenque Juan R, Gegúndez Simón A, Maté P, Prieto-Nieto MI, Rubio-Perez I, Urbieta A, Vicario Bravo M, Abelló D, Frasson M, Garcia-Granero A, Abad Gurumeta A, Abad-Motos A, Lucena-de Pablo E, Nozal B, Ripollés-Melchor J, Salvachúa R, Ferrero E, Garcia-Sancho Tellez L, Ortega Vázquez I, Picardo AL, Rojo López JA, Zorrilla Matilla LP, Cagigas Fernandez C, Castanedo Bezanilla S, Estevez Tesouro J, Fernandez-Diaz MJ, García Cardo J, Gomez Ruiz M, Gonzalez-Tolaretxipi E, Jimeno Fraile J, Poch C, Rodriguez-Aguirre M, Troche Pesqueira N, Trugeda-Carrera MS, de la Torre J, Blanco-Colino R, Espin-Basany E, Espinosa-Bravo M, Morales Comas C, Reyes Afonso E, Rivero Déniz J, Siso Raber C, Verdaguer Tremolosa M, Chandrasinghe P, Kumarage S, Wijekoon Arachchilage N, Senanayake KJ, Abdalla Ahmed Elkamel A, A. Adam M, Saleh M, Blomme N, Thorell A, Wogensen F, Älgå A, Ansarei D, Celebioglu F, Heinius G, Nigard L, Pieniowski E, Ahlqvist S, Björklund I, Cengiz Y, Frånberg A, Håkansson M, Adamo K, Franklin O, Sund M, Wiberg R, Andersson Y, Chabok A, Nikberg M, Kugelberg A, Canonica C, Christoforidis D, Fasolini F, Gaffuri P, Giuliani M, Meani F, Popeskou SG, Pozza S, Wandschneider W, Peterer L, Widmer LW, Zimmermann B, Bakoleas P, Chanousi I, Charalampidou L, Grochola LF, Heid F, Ntaoulas S, Outos M, Peros G, Podolska-Skoczek H, Reinisch KB, Zielasek C, Clerc D, Demartines N, Gilgien J, Kefleyesus A, St-Amour P, Toussaint A, Alhimyar M, Alsaid B, Alyafi A, Alkhaledi A, Kouz B, Omarain A, Al-Sabbagh Y, Alkhatib H, Sara S, Alhaj A, Danial A, Kadoura L, Maa Albared S, Monawar Y, Nahas L, Abd B, Saad A, Wakkaf H, Bouaziz H, Bouzaiene H, Ghalleb M, Akaydin E, Akbaba AC, Atakul O, Baltaci E, Besli S, Burgu G, Cenal U, de Muijnck C, Demirkaya HC, Dogruoz A, Gezer ZI, Gündogdu Y, Kara M, Korkmaz HK, Kurtoglu GK, Ozben V, Ozmen BB, Pektas AM, Sel EK, Yenidünya N, Bengur FB, Oral BM, Yozgatli TK, Abdullayev S, Gunes ME, Sahbaz NA, Banaz T, Kargici K, Kuyumcu OF, Yanikoglu E, Yesilsancak M, Yilmaz D, Aktas MK, Rencuzogullari A, Isik A, Leventoglu S, Yalçinkaya A, Yüksel O, Kalayci MU, Kara Y, Sarici IS, Akin A, Alemdag GN, Arslan E, Baki BE, Bodur MS, Calik A, Candas Altinbas B, Cihanyurdu I, Erkul O, Gül B, Guner A, Köse B, Semiz A, Sevim S, Tayar S, Tomas K, Tüfek OY, Türkyilmaz S, Ulusahin M, Usta A, Yildirim R, Güler SA, Tatar OC, Varol E, Kirimtay B, Uysal M, Yildiz A, Kose E, Ciftci AB, Çolak E, Eraslan H, Kucuk GO, Yemez K, Lule H, Bienfait M, Lule H, Bua E, Doe M, Okalany N, Birindelli A, Basarab M, Bielosludtsev O, Freigofer M, Kolhanova K, Perepelytsia K, Romanukha K, Savenkov D, Siryi S, Tereshchenko M, Viacheslav N, Volovetskyi A, Kebkalo A, Tryliskyy Y, Tyselskiy V, Bruce E, Chow BL, Iddles E, McGuckin S, Newall N, Ramsay G, Sharma P, Stewart C, Wong J, Badran A, Bath M, Belais F, Butt E, Joshi K, Kapur M, Shaw M, Townson A, Williams CYK, Gray T, Greig R, Husain M, Murray E, Mustafa A, Asif A, Gokul A, Shah M, Akitikori MT, Charalabopoulos A, Davidson S, McNally S, Rupani S, Juma F, Mills SC, Muirhead L, Sellars K, Walsh U, Warren O, Chambers A, Hunt R, Teasdale E, Boyce S, Cornwall H, Tol I, Argyriou EO, Eardley N, Povey M, Aithie JMS, Irfan A, McGuigan MC, Starr R, Warren CR, Archibald J, Kirby G, Kisyov I, Khoo CK, Lee R, Photiou D, Davis R, Prasad U, Yang PZ, Bird J, Leung E, Summerour V, Currow C, Kiam J, Tan GJS, Muthusami A, Pegba-Otemolu I, Urbonas T, Nunoo-Mensah J, Smolskas E, Boddy A, Gravante G, Hunter D, Andrew D, Koh A, Thompson A, Adams L, Clements HA, De Silva K, Ekpete O, Haque S, Henderson S, Ibrahim B, Jayasinghe T, Livie J, Mailley K, Nair G, Tan D, Baggaley C, Dawidziuk A, Szyszka B, Barter C, Gandhi N, Hassell K, Hitchin S, Kelsall J, Nagy E, Nessa A, Whisker L, Yanni F, Ali M, Arora D, Hediwattege S, Kumarasinghe N, Rathore M, Tennakoon A, Ali Ahmad SM, Bajomo O, Nadira F, Celentano V, Bhangu A, Glasbey J, Griffiths E, Karri RS, Mak JKC, Nepogodiev D, Pipe M, Bhatti MI, Rabie M, Boyle C, Hamilton D, Mihuna A, Ng JCK, Nicholson G, Oliwa A, Pearson R, Rose A, Yong SQ, Boereboom C, Hanna M, Walter C, Greensmith TS, Mitchell R, Monaghan E, Crawford J, Moug S, Blackwell J, Boyd-Carson H, Herrod P, Al-Allaf O, Beattie M, Bullock C, Burman S, Clark G, Flamey N, Flannery O, Harding A, Kodiatt B, Lawday S, Mahapatra S, Mukundu Nagesh N, Ng M, Rye D, Yoong A, Clark L, Deans C, Edirisooriya M, Fairfield CJ, Harrison EM, Carrington EV, Wong TLE, Yusuf B, Chamberlain C, Duke K, Kmiotek E, Botes A, Condie N, Schrire T, Shah R, Thomas-Jones I, Yates C, Anthony N, Matthews E, Sahnan K, Tankel J, Tucker S, Winter Beatty J, Ziprin P, Duggan W, Kantartzi A, Sridhar S, Khaw RA, Srivastava P, Underwood C, Alves do Canto Brum H, Chopra S, Davis L, Hughes R, Tulley J, Alberts J, Athisayaraj T, Olugbemi M, Ahmad K, Chan C, Chapman G, Fleming H, Fox B, Grewar J, Hulse K, Rutherford D, Sinead M, Smith S, Speake D, Vaughan-Shaw PG, Christodoulides N, Kudhail S, Welch M, Husaini SM, Lambracos S, Anyanwu C, Suresh R, Thomas JS, Gleeson E, Platoff R, Saif A, Enumah Z, Etchill E, Gabre-Kidan A, Bernstein M, Carrano FM, Connors J, Lynn P, Melis M, Newman E, Foster DS, Perrone K, Titan A, Weiser TG, Ahmad S, Bafford ACM, Dal Molin M, Hanna N, Zafar SN, Hemmila M, Napolitano L, Wong JJ, Chandler J, Wood L, Wren S, Ottesen T, You L, Yu K, Arciénega Yañez MDP, Ferreira Fernandes M, González D, Cubas S, González MC, Zubiaurre V, Demolin R, Giroff N, Sciuto P, Campos M, Rodríguez Cantera G, Wagner G, Deepika G, Maimbo M, Simuchimba E, Bulaya A, Chibuye C, Chirengendure B, Kabale MR, Kabongo K, Linyama D, Munthali J, Mweso O, Pikiti F, Otieno J, Chan E, Lai LT, Blackman B, Richards S, Subramaniam S, Karim R, Kok N, Lee YD, Ali S, Sinha A, Corrigan R, Barnes N, Wong F, Dennis G, Jedamzik J, Phillips E, Piette W, Van hentenryck M, Koco H, Lawani S, Kassa MW, Santos Bezerra T, Gribnev P, Dimitrov D, Krastev P, Oum S, Bonghaseh DT, Al Farsi M, Alsharqawi N, Agarwal A, Acevedo V, Castillo Barbosa AC, Giron F, Leon Rodriguez JP, Kucan D, Rosko D, Barsic N, Župan D, Hegazi A, Truncíková V, Fryba V, Mohamed M, Sultan A, Nagi A, Rashad Temerik A, Elshawy ME, Mahmoud MI, Omar S, Anwar M, Rageh T, Elmokadem A, Gaballa K, Teppo S, Turunen A, Pengermä P, Ballouhey Q, Bergeat D, Weyl A, Hain E, Gyedu A, Yenli E, Osei-Poku D, Rompou VA, Zoikas A, Gaitanidis A, Koukis G, Perivoliotis K, Tavlas P, Galanos-Demiris K, Zografos G, Karavokyros I, Xanthopoulou G, Iordanidou E, Ayau F, Garcia A, Damján P, Wason D, B L A, Rangganata E, Kamath P, O'Connor DB, Pinto M, Perrone F, Tropeano FP, Troilo F, Bossi D, Scala D, Pulitanò L, Carella M, Pietrabissa A, Gori A, Giraudo G, De Simone V, Russo AA, Braccio B, Al-Taher R, Athamneh S, Parker A, Sawiee A, Kattia A, Salem M, Tababa O, Shaeeb Z, Syminas V, Jurgaitis J, Damuleviciene G, Svagzdys S, Poskus T, Razafimanjato NNM, Chieng Loo L, Tiong IC, Wan Muhmad WF, Vijeyan H, Li Ying T, Grech G, Arrangoiz R, Jimenez Ley VB, Arizpe D, Jimenez Ley VB, Lagunes Lara E, Castro López EV, Eaazim J, Gordinou de Gouberville M, Bastiaenen V, Rottier S, Nahab F, Ji MY, Seyoji M, Nwachukwu C, Emeghara O, Muhammed SE, Idowu A, Sowemimo O, Ogundoyin O, Akande O, Lott A, Nadeem M, Laghari AA, Loya A, Mushtaq H, Abdullah MT, Abuhilal B, Atawneh M, Hamdan H, Alhabil B, Srour A, Mousa I, Da Silva Medina L, Sacdalan MD, Lapitan MC, Sacdalan MD, Sacdalan MD, Bartosiak K, Ferreira P, Francisco V, Lemos R, Frutuoso L, Fernandes S, Fonseca T, Pereira J, Rachadell J, Torre A, Madeira Martins F, Carvalho AC, Rodrigues Ferreira J, Ribeiro da Silva B, Devesa H, Vieira A, Mónica I, Amaro M, Sousa D, Reia M, Louro J, Martins A, Dominguez J, Santos I, Freitas Oliveira NM, Pereira JC, Silva-Vaz P, Freire L, Escrevente R, Negoita VM, Shakhmatov D, Nezerwa Y, Radulovic R, Moore R, Obery G, Viljoen F, Mendes T, Suarez A, Moncada E, Fernandez-Hevia M, Curtis Martínez C, Gil Garcia JM, González Zunzarren M, Idris T, Eklöv K, Grahn O, Amin L, Blomqvist M, Ajani C, Kraus R, Seeger N, Willemin M, Rayya F, Ayash M, Msouti R, Kannas I, Abazid E, Esper A, Slim S, Kavcar AS, Aytac E, Dural AC, Ilker A, Eray IC, Kurnaz E, Altiner S, Tepe MD, Sahin C, Savli E, Innocent A, Babirye L, Diachenko A, Hordoskiy V, Curry H, Chau CYC, Robertson H, Mahmoud A, Lennon H, Loi L, Kirkham E, McCann C, Watts D, Gurung B, Wilson M, Tribedi T, Garofalo E, Zahra B, MacDonald S, Daniels I, Ng N, Khosla S, Olivier J, Yue SYP, Suresh G, Wellington J, Lorejo E, Mossaad M, Tryliskyy Y, Crutcher M, Alimi M, Baiu I, Abdou H, Conway A, Peck C, Wagner G, Perdomo Perez MA, Trostchansky I, Zulu S, Nakazwe M, Knight SR, Drake TM, Nepogodiev D, Fitzgerald JE, Ademuyiwa A, Alexander P, Ingabire JA, Al-Saqqa SW, Biccard BM, Borda-Luque G, Borowski DW, Burger S, Chu K, Clarke D, Costas-Chavarri A, Davies J, Donaldson R, Ede C, Garden OJ, Ghosh D, Glasbey J, Kingham TP, Salem HK, Anyomih TTK, Koto MZ, Lapitan MC, Lawani I, Lesetedi C, Aguilera-Arevalo ML, Mabedi C, Maimbo M, Magill L, Makinde Alakaloko F, Makupe A, Martin J, Ramos-De la Medina A, Monahan M, Moore R, Msosa V, Mulira S, Mutabazi AZ, Muller E, Musowoyo J, Adisa AO, Olory-Togbe JL, Pius R, Qureshi AU, Rayne S, Roberts T, Sacdalan MD, Shaw CA, Smart N, Smith M, Spence R, Van Straten S, Tabiri S, Tayler V, Weiser TG, Windsor J, Yorke J, Yepez R, Lilford R, Morton D, Bhangu A, Sundar S, Harrison EM, Runigamugabo E, Verjee A, Chen J, Daya L, El Aroussi N, Farina V, Gnintedeme Olivier T, Gonzales Nacarino M, Hammani A, Honjo S, Jacobs R, Kimura H, Litvin A, Nkoronko M, Nour I, Oscullo Yepez JJ, Pagano G, Pata F, Pin Hung W, Raj A, Romani Pozo A, Rommaneh M, Sassamela Fabiano SC, Shiroma Gago CM, Shu Yip S, Srinivas A, Sung CY, Tai A, Valle Aranda YC, Venturini S, Vervoort D, Wilguens Lartigue J. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet 2021; 397:387-397. [PMID: 33485461 PMCID: PMC7846817 DOI: 10.1016/s0140-6736(21)00001-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. METHODS This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. FINDINGS Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. INTERPRETATION Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. FUNDING National Institute for Health Research Global Health Research Unit.
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Abstract
INTRODUCTION Malnutrition is prevalent in hospitalized surgical patients and has been shown to significantly alter outcomes including length of hospital stay, complications, and mortality. Different tools for nutrition assessment were developed and are being used. The aim of this study was to characterize the nutritional status of acute care surgery patients, determine risk factors for malnutrition, and describe outcomes in patients with malnutrition. METHODS This was a prospective, descriptive study of malnutrition in acute care surgery patients at CHUK. Over a 6-month time period, we collected data on demographics, diagnosis, operation, and patient outcomes. We assessed the incidence of malnutrition using the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and Subjective Global Assessment (SGA). We reported frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables. RESULTS We analyzed data for 279 acute care surgery patients. Most (n = 209, 73%) patients were male. The median duration of symptoms was 5 days (IQR 2, 14). The most common diagnoses were trauma (n = 83, 30%), intestinal obstruction (n = 76, 27%), and peritonitis (n = 49, 18%). Most (n = 210, 73%) patients underwent operation. The median length of hospital stay was 6 days (IQR 4, 11). Using ASPEN guidelines, 99 (35%) patients had evidence of malnutrition on hospital admission and 76 (27%) had evidence of malnutrition using SGA. After 1 week of hospital stay, 48 (41%) patients had evidence of malnutrition. Overall mortality was 3%, with higher mortality seen in patients with malnutrition (8% vs. 0.6%, p = 0.001). The length of hospital stay was longer in patients with malnutrition on hospital admission (6 days vs. 5 days, p = 0.044). CONCLUSIONS Acute care surgical patients present to the hospital at high-risk for malnutrition. Efforts are needed to ensure that surgical patients receive adequate nutrition support to improve patient outcomes and minimize complications.
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Affiliation(s)
- Egide Abahuje
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
- Kigali University Teaching Hospital, Kigali, Rwanda.
| | - Irenee Niyongombwa
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - David Karenzi
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Eugene Tuyishime
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Faustin Ntirenganya
- University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
- Kigali University Teaching Hospital, Kigali, Rwanda
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Sibomana I, Karenzi ID, Niyongombwa I, Byiringiro JC, Gashegu J, Ntirenganya F. Use of Student-Generated Multiple Choice Questions to Enhance Team-Based Learning of Anatomy at the University of Rwanda. Adv Med Educ Pract 2020; 11:825-832. [PMID: 33177911 PMCID: PMC7650038 DOI: 10.2147/amep.s274298] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/02/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Isaie Sibomana
- Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Irenee David Karenzi
- Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Irenee Niyongombwa
- Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Julien Gashegu
- Department of Anatomy, College of Medicine and Health Sciences, University of Rwanda, Butare, Rwanda
| | - Faustin Ntirenganya
- Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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Murthy SS, Ntakiyiruta G, Ntirenganya F, Ingabire A, Defregger SK, Reznor G, Lipitz S, Troyan SL, Raza S, Dunnington G, Riviello R. A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda. J Surg Educ 2020; 77:1161-1168. [PMID: 32241670 DOI: 10.1016/j.jsurg.2020.02.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 02/15/2020] [Revised: 02/24/2020] [Accepted: 02/29/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Shilpa Shree Murthy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Indiana University, Bloomington, Indiana.
| | | | | | | | - Sara Kikut Defregger
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Indiana University, Bloomington, Indiana; University of Rwanda, Department of Surgery, Rwanda; Massachusetts General Hospital, Boston, Massachusetts; Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Gally Reznor
- Massachusetts General Hospital, Boston, Massachusetts
| | - Stu Lipitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan Lynn Troyan
- Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Sughra Raza
- Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; University of Rwanda, Department of Surgery, Rwanda
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Rosenberg A, Ntirenganya F, Bagahirwa I, Mbanjumucyo G, Rutayisire L, Muneza S, Nzeyimana I, Benimana E, Nahayo E, Bhengu B, Nuhu A, Muhumuza A, Uwitonze C, Umwali G, Nkeshimana M, Nyinawankusi JD, Krebs E, Uwitonze JM, Kabagema I, Dushime T, Byiringiro JC, Ndayisaba G, Jayaraman S. First Rwanda National Trauma Symposium 2019: Challenges and priorities. J Glob Health 2020; 10:010201. [PMID: 32257131 PMCID: PMC7100625 DOI: 10.7189/jogh.10.010201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Ashley Rosenberg
- Virginia Commonwealth University Department of Surgery, Richmond, Virginia, USA
- Joint first authorship
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
- Joint first authorship
| | | | - Gabin Mbanjumucyo
- University Teaching Hospital of Kigali Department of Accident and Emergency, Kigali, Rwanda
| | - Lambert Rutayisire
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
| | - Severien Muneza
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
| | - Innocent Nzeyimana
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
| | | | - Ernest Nahayo
- Rwanda Military Hospital Department of Accident and Emergency, Kigali, Rwanda
| | | | - Assuman Nuhu
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Arsene Muhumuza
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Ghislaine Umwali
- Collaboration for Evidence-based Healthcare and Public Health in Africa, Kigali, Rwanda
| | - Menelas Nkeshimana
- University Teaching Hospital of Kigali Department of Accident and Emergency, Kigali, Rwanda
| | | | - Elizabeth Krebs
- Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Igance Kabagema
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
| | - Theophile Dushime
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Gilles Ndayisaba
- Rwanda Biomedical Center, Department of Noncommunicable Diseases, Kigali, Rwanda
| | - Sudha Jayaraman
- Virginia Commonwealth University Department of Surgery, Richmond, Virginia, USA
- Virginia Commonwealth University Program for Global Surgery, Richmond, Virginia, USA
| | - on behalf of the participants for the first national Rwanda Trauma Symposium 2019 in Kigali, Rwanda
- Virginia Commonwealth University Department of Surgery, Richmond, Virginia, USA
- University Teaching Hospital of Kigali Department of Surgery, Kigali, Rwanda
- Rwanda Biomedical Center, Kigali, Rwanda
- University Teaching Hospital of Kigali Department of Accident and Emergency, Kigali, Rwanda
- Rwanda National Police, Kigali, Rwanda
- Rwanda Military Hospital Department of Accident and Emergency, Kigali, Rwanda
- University of Rwanda School of Nursing, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- Rwanda Association for Biomedical Engineering, Kigali, Rwanda
- Collaboration for Evidence-based Healthcare and Public Health in Africa, Kigali, Rwanda
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
- Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
- Rwanda Biomedical Center, Department of Noncommunicable Diseases, Kigali, Rwanda
- Virginia Commonwealth University Program for Global Surgery, Richmond, Virginia, USA
- Joint first authorship
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Dworkin M, Cyuzuzo T, Hategekimana JDD, Katabogama J, Ntirenganya F, Rickard J. Barriers to Surgical Care at a Tertiary Hospital in Kigali, Rwanda. J Surg Res 2020; 250:148-155. [DOI: 10.1016/j.jss.2019.12.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 12/02/2019] [Accepted: 12/29/2019] [Indexed: 10/25/2022]
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Shumbusho JP, Duanmu Y, Kim SH, Bassett IV, Boyer EW, Ruutiainen AT, Riviello R, Ntirenganya F, Henwood PC. Accuracy of Resident-Performed Point-of-Care Lung Ultrasound Examinations Versus Chest Radiography in Pneumothorax Follow-up After Tube Thoracostomy in Rwanda. J Ultrasound Med 2020; 39:499-506. [PMID: 31490569 PMCID: PMC7028462 DOI: 10.1002/jum.15126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/11/2019] [Indexed: 05/19/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the accuracy and timeliness of resident-performed point-of-care lung ultrasound (LUS) examinations for the follow-up of pneumothorax (PTX) after tube thoracostomy. METHODS After brief training, Rwandan surgical residents blinded to chest radiography (CXR) performed and interpreted LUS examinations for PTX in participants undergoing CXR for PTX follow-up. Treating clinicians interpreted CXR for the presence of PTX for therapeutic decisions. Lung ultrasound was later reviewed by ultrasound experts, and CXR was reviewed by a radiologist. We defined expert LUS interpretation as the reference standard. The sensitivity and specificity of resident-performed LUS examinations for diagnosing PTX were calculated. We assessed agreement between trained resident versus expert LUS and clinician versus radiology CXR using the Cohen κ coefficient. We compared the time to results between LUS and CXR. RESULTS Over an 8-month period, 51 participants were enrolled. Compared to expert LUS interpretation, the sensitivity and specificity (95% confidence intervals) of resident LUS were 100% (85%-100%) and 96% (82%-100%), respectively, whereas the sensitivity and specificity of clinician-interpreted CXR were 48% (27%-69%) and 100% (88%-100%). The agreement between resident and expert LUS was excellent (κ = 0.96), whereas the agreement between clinician and radiologist CXR was only moderate (κ = 0.60). The time to results was significantly longer for CXR than LUS (mean, 1335 versus 396 minutes; P = .0001). CONCLUSIONS A resident-performed LUS examination was a quicker imaging modality with superior sensitivity compared to clinician-interpreted CXR for PTX follow-up after tube thoracostomy in this Rwandan study. Lung ultrasound can be a valuable imaging tool for PTX follow-up, especially in resource-limited settings.
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Affiliation(s)
| | - Youyou Duanmu
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sung H Kim
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward W Boyer
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander T Ruutiainen
- Department of Radiology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Robert Riviello
- Global Surgery Program, Brigham and Women's Hospital, Center for Surgery and Pubic Health, Boston, Massachusetts, USA
| | - Faustin Ntirenganya
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Murthy SS, Ntirenganya F, Scott JW, Ingabire A, Rosman D, Raza S, Troyan S, Dunnington G, Reznor G, Lipitz S, Ntakiyiruta G, Riviello R. A Randomized Cross-Over Trial Focused on Breast Core Needle Biopsy Skill Acquisition and Safety Using High Fidelity Versus Low Fidelity Simulation Models in Rwanda. J Surg Educ 2020; 77:404-412. [PMID: 31902690 DOI: 10.1016/j.jsurg.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/11/2019] [Accepted: 11/07/2019] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Breast cancer is the most common cancer diagnosed in low and middle-income countries. Growing the number of health care personnel trained in diagnostic procedures like breast core needle biopsy (BCNB) is critical. We developed a BCNB simulation-training course that evaluated skill acquisition, confidence, and safety, comparing low-cost low fidelity (LF) models to expensive high fidelity (HF) models. DESIGN A single-center randomized education crossover trial was implemented. Participants were randomized to HF or LF groups. A preintervention baseline exam followed by lectures and training sessions with a HF or LF model was implemented. A postintervention simulation exam was conducted, and participants crossed over to the other simulation model. SETTING The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from October 2014 to March 2015. PARTICIPANTS Residents training in surgery or obstetrics and gynecology participated in a 1-day BCNB training course. RESULTS A total of 36 residents were analyzed, 19 in the HF arm and 17 in the LF arm. Mean difference in exam scores for HF and LF groups in the baseline exam (exam 1) (0.067, p = 0.94, standard error [SE] of 1.57) postintervention exam (exam 2) (1.85, SE 1.46, p = 0.33), and the crossover exam (exam 3) (4.39, SE = 1.90, p = 0.11) were not significantly different between HF and LF. Overall exam scores improved from pre- to postintervention. CONCLUSIONS Our results indicate that mean difference in exams scores were not significantly different between residents trained with HF versus LF models. In resources poor areas-LF models can be utilized as effective teaching tools for skill acquisition for diagnostic surgical procedures.
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Affiliation(s)
- Shilpa S Murthy
- Indiana University, Department of Surgery, Bloomington, Indiana; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | | | - John W Scott
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Allen Ingabire
- University of Rwanda, Department of Surgery, Kigali, Rwanda
| | - David Rosman
- Massachusetts General Hospital, Boston, Massachusetts
| | - Sughra Raza
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan Troyan
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gary Dunnington
- Indiana University, Department of Surgery, Bloomington, Indiana
| | - Gally Reznor
- Massachusetts General Hospital, Boston, Massachusetts
| | - Stu Lipitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert Riviello
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; University of Rwanda, Department of Surgery, Kigali, Rwanda
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Tuyishime E, Banguti PR, Mvukiyehe JP, Ntirenganya F, Durieux M, Cattermole G. Using the World Society of Emergency Surgery (WSES) Triage Tool to Evaluate Timing of Emergency Surgery in Rwanda. World J Surg 2020; 44:1387-1394. [DOI: 10.1007/s00268-020-05372-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Munabi NCO, Durnwald L, Nagengast ES, Ntirenganya F, Magee Iii WP. Long-Term Impact of a Mission-Based Surgical Training Rotation on Plastic Surgery Capacity Building in Rwanda. J Surg Educ 2020; 77:124-130. [PMID: 31492640 DOI: 10.1016/j.jsurg.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 05/30/2019] [Revised: 07/13/2019] [Accepted: 08/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Short-term, high-volume surgical training experiences can lead to successful skills transfer and be an effective method of training surgical providers in low-resource settings. However, immediate skills acquisition does not guarantee long-term performance of surgical procedures by trainees. This study aims to determine the long-term impact of a short-term plastic surgery training rotation (STR) on general surgeon contribution to plastic surgery capacity building in Rwanda. DESIGN A retrospective survey study was conducted. Surveys were distributed to credentialed general surgeons who previously participated in the Operation Smile STR in Rwanda. Questions focused on exposure to procedures during the rotation and current practice demographics. The percentage of current practice volumes dedicated to plastic surgery was mapped to demonstrate participant contribution to plastic surgery capacity in the country. SETTING Surveys were distributed remotely. Surgeon respondents previously participated in the STR at the Rwinkwavu District Hospital, a primary level hospital in eastern Rwanda. PARTICIPANTS All 8 prior participants of the STR who completed residency and are currently practicing as general surgeons in Rwanda were included. RESULTS Six out of 8 prior participants completed the survey (75.0%). All respondents work as general surgeons in governmental hospitals around the country. Up to 75% of surgeon caseloads are dedicated to plastic surgery procedures. Half of respondents work in regions without a credentialed plastic surgeon. Exposure to cleft and congenital hand surgery during the rotation did not lead to durable performance in practice. All participants felt the rotation improved their performance in multiple core competencies. CONCLUSION Participation in a short-term plastic surgery training experience in Rwanda was associated with increased long-term surgical capacity in the country through a task-sharing model. A mission-based rotation may provide sufficient exposure for basic plastic surgery procedures, but does not provide enough volume or time to durably teach more complicated surgeries such as cleft repair. Further studies are needed to determine how longer durations of training exposure impacts long-term performance of plastic surgery procedures.
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Affiliation(s)
- Naikhoba C O Munabi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Operation Smile, Inc., Virginia Beach, Virginia
| | | | - Eric S Nagengast
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Operation Smile, Inc., Virginia Beach, Virginia
| | - Faustin Ntirenganya
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - William P Magee Iii
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, Los Angeles, California; Division of Plastic Surgery, Shriner's Hospital, Los Angeles, California.
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Munabi NCO, Durnwald L, Nagengast E, Auslander A, Ntirenganya F, Magee WP. Pilot Evaluation of the Impact of a Mission-Based Surgical Training Rotation on the Plastic Surgery Skills and Competencies Development of General Surgery Residents in Rwanda. J Surg Educ 2019; 76:1579-1587. [PMID: 31130506 DOI: 10.1016/j.jsurg.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 01/31/2019] [Revised: 03/11/2019] [Accepted: 05/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Increasing subspecialty surgical capacity in Rwanda requires innovative approaches to augment the skills of pre-existing surgical providers. Short-term, high-intensity training programs can be effective for surgical education, however, few studies have investigated the quality of skills acquired through a condensed surgical experience. This study aims to determine the efficacy of a 3-week surgical training rotation (STR) to teach plastic surgery skills to general surgery residents in Rwanda. DESIGN A survey-based, prospective observational study of general surgery residents and volunteer plastic surgery educators participating in an Operation Smile STR. Resident self-assessment scores of surgical capabilities at the beginning and end of the rotation were compared to surgeon evaluation of resident performance. Progression of resident performance and change in inter-rater reliability between residents and educators were analyzed. Student's t test with significance at p < 0.05 was used to confirmed statistical significance. SETTING This study took place during the Operaiton Smile STR at the Rwinkwavu District Hospital, a primary level hospital in Rwinkwavu, Rwanda. PARTICIPANTS All residents (5) and surgeon evaluators (4) who participated in the STR were included in this study. All study participants completed all study surveys. RESULTS Residents reported a significant increase in confidence with the majority of procedures performed by the end of the rotation. Surgeons identified significant improvement in all resident skills by 2 weeks (p < 0.05). Resident ability to perform self-assessment improved, as determined by a significant decrease in inter-rater error margin from -0.61 to -0.10 over the course of the rotation (p < 0.01). CONCLUSIONS In this pilot study, a 3 week rotation improved surgical competencies and technical skills of general surgery residents learning plastic surgery. These findings support using the short-term STR as a method for task-sharing education. Further studies are needed to determine durability of skills transfer and long-term impact on surgical capacity.
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Affiliation(s)
- Naikhoba C O Munabi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Eric Nagengast
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Allyn Auslander
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Faustin Ntirenganya
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - William P Magee
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, Los Angeles, California; Division of Plastic Surgery, Shriner's Hospital, Los Angeles, California.
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Munyaneza M, Jayaraman S, Ntirenganya F, Rickard J. Factors Influencing Seeking and Reaching Care in Patients With Peritonitis in Rwanda. J Surg Res 2019; 246:236-242. [PMID: 31610351 DOI: 10.1016/j.jss.2019.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 05/02/2019] [Revised: 08/29/2019] [Accepted: 09/13/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Peritonitis is an emergency which frequently requires surgical intervention. The aim of this study was to describe factors influencing seeking and reaching care for patients with peritonitis presenting to a tertiary referral hospital in Rwanda. METHODS This was a cross-sectional study of patients with peritonitis admitted to University Teaching Hospital of Kigali. Data were collected on demographics, prehospital course, and in-hospital management. Delays were classified according to the Three Delays Model as delays in seeking or reaching care. Chi square test and logistic regression were used to determine associations between delayed presentation and various factors. RESULTS Over a 9-month period, 54 patients with peritonitis were admitted. Twenty (37%) patients attended only primary school and 15 (28%) never went to school. A large number (n = 26, 48%) of patients were unemployed and most (n = 45, 83%) used a community-based health insurance. For most patients (n = 44, 81%), the monthly income was less than 10,000 Rwandan francs (RWF) (11.90 U.S. Dollars [USD]). Most (n = 51, 94%) patients presented to the referral hospital with more than 24 h of symptoms. More than half (n = 31, 60%) of patients had more than 4 d of symptoms on presentation. Most (n = 37, 69%) patients consulted a traditional healer before presentation at the health care system. Consultation with a traditional healer was associated with delayed presentation at the referral hospital (P < 0.001). Most (n = 29, 53%) patients traveled more than 2 h to reach a health facility and this was associated with delayed presentation (P = 0.019). The cost of transportation ranged between 5000 and 1000 RWF (5.95-11.90 USD) for most patients and was not associated with delayed presentation (P = 0.449). CONCLUSIONS In this study, most patients with peritonitis present in a delayed fashion to the referral hospital. Factors associated with seeking and reaching care included sociodemographic characteristics, health-seeking behaviors, cost of care, and travel time. These findings highlight factors associated with delays in seeking and reaching care for patients with peritonitis.
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Affiliation(s)
- Martin Munyaneza
- Department of Surgery, University of Rwanda, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Butare, Butare, Rwanda
| | - Sudha Jayaraman
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Faustin Ntirenganya
- Department of Surgery, University of Rwanda, Kigali, Rwanda; Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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Mpirimbanyi C, Abahuje E, Hirwa AD, Gasakure M, Rwagahirima E, Niyonzima C, Hakizimana AN, Ishimwe E, Ntirenganya F, Rickard J. Defining the Three Delays in Referral of Surgical Emergencies from District Hospitals to University Teaching Hospital of Kigali, Rwanda. World J Surg 2019; 43:1871-1879. [PMID: 30944958 DOI: 10.1007/s00268-019-04991-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Surgical conditions represent up to 30% of the global burden of diseases. The aim of this study was to assess the delays in patients transferred to a tertiary referral hospital from district hospitals (DHs) in Rwanda with emergency general surgery (EGS) conditions. METHODS We performed a prospective review of all EGS patients referred from DH over a 3-month period to assess delays in transfer and accessing care. We then surveyed general practitioners to define their perspective on delays in surgical care. RESULTS Over a 3-month period, there were 86 patients transferred from DH with EGS conditions. The most common diagnoses were bowel obstruction (n = 22, 26%) and trauma (n = 19, 22%). The most common performed operations were laparotomy (n = 21, 24%) and bowel resection (n = 20, 23%). The mortality rate was 12%, and the intensive care unit admission rate was 4%. In transfer to the referral hospital, 5% patients were delayed for financial reasons and 2% due to lack of insurance. After reaching CHUK, 5% patients were delayed due to laboratory and radiology issues. Other delays included no operating theater available (4%) and no surgeon available (1%). Providers' perceptions for not performing surgeries at DH were predominantly the lack of a competent surgical provider or anesthesia staff. CONCLUSION EGS patients represent a broad range of diagnoses. Delays were noted at each step in the referral process with multiple areas for potential improvement. Expanding surgical access at the DH has the potential to decrease delays and thereby improves patient outcomes.
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Affiliation(s)
- Christophe Mpirimbanyi
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Egide Abahuje
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Aime Dieudone Hirwa
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Miguel Gasakure
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Elisee Rwagahirima
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Christian Niyonzima
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | | | - Epiphanie Ishimwe
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University Teaching Hospital of Kigali, Kigali, Rwanda.,University of Minnesota, Minneapolis, MN, USA
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Rickard J, Ntirenganya F, Ntakiyiruta G, Chu K. Global Health in the 21st Century: Equity in Surgical Training Partnerships. J Surg Educ 2019; 76:9-13. [PMID: 30093332 DOI: 10.1016/j.jsurg.2018.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 03/18/2018] [Revised: 06/17/2018] [Accepted: 07/10/2018] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Safe and affordable surgical care has been recognized as an important component of global health. One of the challenges in providing safe and affordable surgical care is the shortage of trained surgical workforce. Partnerships have developed between institutions in high-income countries (HICs) and low- and middle-income countries (LMICs) to strengthen and expand surgical education in LMICs. As these relationships evolve, emphasis needs to focus on development of equitable, bilateral partnerships. METHODS We reviewed different global surgery education partnerships to describe key components and features of successful partnerships. We then provide a framework for equitable global surgical training partnerships. RESULTS Key features of equitable global surgical education partnerships included an alignment with local priorities, long term collaborations, and locally integrated, competency-based training. To develop a partnership, both parties must meet and perform a needs assessment of the LMIC institution and jointly agree how the partnership can best address these needs. Both the HIC and LMIC institutions must clearly define their goals and expectations. Ideally, a set of output measures will be defined to assess the success of the partnership. CONCLUSIONS Improving surgical education in LMIC countries is an integral part of health equity in global surgery. Key components of equitable education partnerships focus on local ownership and long-term relationships. Each party needs to clearly define goals and expectations for the partnership. Equity is essential and unequal relationships must be avoided.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
| | | | | | - Kathryn Chu
- Department of Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town
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Cancedda C, Cotton P, Shema J, Rulisa S, Riviello R, Adams LV, Farmer PE, Kagwiza JN, Kyamanywa P, Mukamana D, Mumena C, Tumusiime DK, Mukashyaka L, Ndenga E, Twagirumugabe T, Mukara KB, Dusabejambo V, Walker TD, Nkusi E, Bazzett-Matabele L, Butera A, Rugwizangoga B, Kabayiza JC, Kanyandekwe S, Kalisa L, Ntirenganya F, Dixson J, Rogo T, McCall N, Corden M, Wong R, Mukeshimana M, Gatarayiha A, Ntagungira EK, Yaman A, Musabeyezu J, Sliney A, Nuthulaganti T, Kernan M, Okwi P, Rhatigan J, Barrow J, Wilson K, Levine AC, Reece R, Koster M, Moresky RT, O’Flaherty JE, Palumbo PE, Ginwalla R, Binanay CA, Thielman N, Relf M, Wright R, Hill M, Chyun D, Klar RT, McCreary LL, Hughes TL, Moen M, Meeks V, Barrows B, Durieux ME, McClain CD, Bunts A, Calland FJ, Hedt-Gauthier B, Milner D, Raviola G, Smith SE, Tuteja M, Magriples U, Rastegar A, Arnold L, Magaziner I, Binagwaho A. Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda. Int J Health Policy Manag 2018; 7:1024-1039. [PMID: 30624876 PMCID: PMC6326644 DOI: 10.15171/ijhpm.2018.61] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/19/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.
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Affiliation(s)
- Corrado Cancedda
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Phil Cotton
- Office of the Vice-Chancellor, University of Rwanda, Kigali, Rwanda
| | - Joseph Shema
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Stephen Rulisa
- Office of the Dean, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Lisa V. Adams
- Center for Health Equity, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Paul E. Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jeanne N. Kagwiza
- Office of the Principal, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Patrick Kyamanywa
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University - Western Campus, Ishaka, Uganda
| | - Donatilla Mukamana
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Chrispinus Mumena
- Office of the Dean and Department of Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - David K. Tumusiime
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Lydie Mukashyaka
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Esperance Ndenga
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Theogene Twagirumugabe
- Department of Anesthesiology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Kaitesi B. Mukara
- Department of Ear, Nose, and Throat, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Vincent Dusabejambo
- Department of Internal Medicine, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Timothy D. Walker
- Department of Internal Medicine, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
- Department of General Medicine, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Emmy Nkusi
- Department of Neurosurgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Lisa Bazzett-Matabele
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Alex Butera
- Department of Orthopedic Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Belson Rugwizangoga
- Department of Pathology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Kabayiza
- Department of Pediatrics, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Simon Kanyandekwe
- Department of Mental Health, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Louise Kalisa
- Department of Radiology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Faustin Ntirenganya
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Tanya Rogo
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Pediatrics, BronxCare Health System, Bronx, NY, USA
| | - Natalie McCall
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Mark Corden
- Division of Hospital Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rex Wong
- Global Health Leadership Institute, Yale School of Public Health, New Haven, CT, USA
| | - Madeleine Mukeshimana
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Agnes Gatarayiha
- Office of the Dean and Department of Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Preventive and Community Dentistry, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Egide Kayonga Ntagungira
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Attila Yaman
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Anne Sliney
- Clinton Health Access Initiative, Boston, MA, USA
| | | | | | - Peter Okwi
- Clinton Health Access Initiative, Kigali, Rwanda
| | - Joseph Rhatigan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jane Barrow
- Office of Global and Community Health, Harvard School of Dental Medicine, Boston, MA, USA
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA
| | - Kim Wilson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Adam C. Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rebecca Reece
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael Koster
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rachel T. Moresky
- sidHARTe Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, NY, USA
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | - Jennifer E. O’Flaherty
- Department of Anesthesiology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Paul E. Palumbo
- Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Rashna Ginwalla
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | | | - Nathan Thielman
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Michael Relf
- Duke Global Health Institute, Durham, NC, USA
- Duke University School of Nursing, Durham, NC, USA
| | - Rodney Wright
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, New York City, NY, USA
- Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center, New York City, NY, USA
| | - Mary Hill
- Division of Nursing, Howard University College of Nursing and Allied Health Sciences, Washington, DC, USA
| | - Deborah Chyun
- University of Connecticut School of Nursing, Storrs, CT, USA
| | - Robin T. Klar
- New York University Rory Meyers College of Nursing, New York City, NY, USA
| | - Linda L. McCreary
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Tonda L. Hughes
- Columbia University School of Nursing, New York City, NY, USA
| | - Marik Moen
- Department of Family & Community Health, University of Maryland School of Nursing, Baltimore, MD, USA
- Global Education and Mentorship, Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Valli Meeks
- Department of Oncology & Diagnostic Sciences, University of Maryland School of Dentistry, Baltimore, MD, USA
| | - Beth Barrows
- Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA
- Partnerships, Professional Education, and Practice, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Craig D. McClain
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Amy Bunts
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Forrest J. Calland
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Danny Milner
- Center for Global Health, American Society for Clinical Pathology, Chicago, IL, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Giuseppe Raviola
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA, USA
| | - Stacy E. Smith
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Meenu Tuteja
- Global Health and Research Programs, Biomedical Research Institute, Brigham and Women’s Hospital, Boston MA, USA
| | - Urania Magriples
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Asghar Rastegar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Linda Arnold
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | | | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
- Office of the Vice-Chancellor, University of Global Health Equity, Kigali, Rwanda
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Redko C, Bessong P, Burt D, Luna M, Maling S, Moore C, Ntirenganya F, Martin AN, Petroze R, den Hartog J, Ballard A, Dillingham R. Exploring the Significance of Bidirectional Learning for Global Health Education. Ann Glob Health 2018; 82:955-963. [PMID: 28314497 DOI: 10.1016/j.aogh.2016.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Cristina Redko
- Center for Global Health, Department of Population and Public Health Sciences, Wright State University Boonshoft School of Medicine, Dayton, OH.
| | - Pascal Bessong
- HIV/AIDS and Global Health Research Program, Professor of Microbiology, University of Venda, Thohoyandou, South Africa
| | - David Burt
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Max Luna
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Samuel Maling
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Christopher Moore
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | | | - Allison N Martin
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Robin Petroze
- Department of Surgery, McGill University, Montreal, Quebec
| | - Julia den Hartog
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - April Ballard
- Center for Global Health, University of Virginia, Charlottesville, VA
| | - Rebecca Dillingham
- Center for Global Health, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA
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Abstract
BACKGROUND The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa. METHODS An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery. RESULTS A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees. CONCLUSION The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills.
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Affiliation(s)
| | | | - Georges Ntakiyiruta
- Ejo Heza Surgical Centre, KN 25, St 9, Kiyovu Sector, Nyarugenge District, Ishema Village, Kigali, Rwanda
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44
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Lin Y, Scott JW, Yi S, Taylor KK, Ntakiyiruta G, Ntirenganya F, Banguti P, Yule S, Riviello R. Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum. J Surg Educ 2018; 75:1014-1021. [PMID: 29074364 DOI: 10.1016/j.jsurg.2017.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 07/02/2017] [Revised: 09/03/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety. DESIGN The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety. SETTING The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda. PARTICIPANTS Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%). RESULTS In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, p<0.01). All residents reported that the course would improve their ability to provide safer patient care, and 97.4% believed developing nontechnical skills would improve patient outcomes. CONCLUSIONS Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global surgical safety.
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Affiliation(s)
- Yihan Lin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Colorado School of Medicine, Denver, Colorodo.
| | - John W Scott
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sojung Yi
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Kathryn K Taylor
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Georges Ntakiyiruta
- Department of Surgery, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Faustin Ntirenganya
- Department of Surgery, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Paulin Banguti
- Department of Anesthesia, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Steven Yule
- Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; STRATUS Center for Medical Simulation, Brigham & Women's Hospital, Boston, Massachusetts
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda; STRATUS Center for Medical Simulation, Brigham & Women's Hospital, Boston, Massachusetts
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Bhangu A, Ademuyiwa AO, Aguilera ML, Alexander P, Al-Saqqa SW, Borda-Luque G, Costas-Chavarri A, Drake TM, Ntirenganya F, Fitzgerald JE, Fergusson SJ, Glasbey J, Ingabire JCA, Ismaïl L, Salem HK, Kojo ATT, Lapitan MC, Lilford R, Mihaljevic AL, Morton D, Mutabazi AZ, Nepogodiev D, Adisa AO, Ots R, Pata F, Pinkney T, Poškus T, Qureshi AU, Ramos-De la Medina A, Rayne S, Shaw CA, Shu S, Spence R, Smart N, Tabiri S, Harrison EM, Khatri C, Mohan M, Jaffry Z, Altamini A, Kirby A, Søreide K, Recinos G, Cornick J, Modolo MM, Iyer D, King S, Arthur T, Nahar SN, Waterman A, Walsh M, Agarwal A, Zani A, Firdouse M, Rouse T, Liu Q, Correa JC, Talving P, Worku M, Arnaud A, Kalles V, Kumar B, Kumar S, Amandito R, Quek R, Ansaloni L, Altibi A, Venskutonis D, Zilinskas J, Poskus T, Whitaker J, Msosa V, Tew YY, Farrugia A, Borg E, Bentounsi Z, Gala T, Al-Slaibi I, Tahboub H, Alser OH, Romani D, Shu S, Major P, Mironescu A, Bratu M, Kourdouli A, Ndajiwo A, Altwijri A, Alsaggaf MU, Gudal A, Jubran AF, Seisay S, Lieske B, Ortega I, Jeyakumar J, Senanayake KJ, Abdulbagi O, Cengiz Y, Raptis D, Altinel Y, Kong C, Teasdale E, Irwin G, Stoddart M, Kabariti R, Suresh S, Gash K, Narayanan R, Maimbo M, Grizhja B, Ymeri S, Galiqi G, Klappenbach R, Antezana D, Mendoza Beleño AE, Costa C, Sanchez B, Aviles S, Fermani CG, Balmaceda R, Villalobos S, Carmona JM, Hamill D, Deutschmann P, Sandler S, Cox D, Nataraja R, Sharpin C, Ljuhar D, Gray D, Haines M, Iyer D, Niranjan N, D'Amours S, Ashtari M, Franco H, Rahman Mitul A, Karim S, Aman NF, Estee MM, Salma U, Razzaque J, Hamid Kanta T, Tori SA, Alamin S, Roy S, Al Amin S, Karim R, Haque M, Faruq A, Iftekhar F, O'Shea M, Padmore G, Jonnalagadda R, Litvin A, Filatau A, Paulouski D, Shubianok M, Shachykava T, Khokha D, Khokha V, Djivoh F, Dossou F, Seto DM, Gbessi DG, Noukpozounkou B, Imorou Souaibou Y, Keke KR, Hodonou F, Ahounou EYS, Alihonou T, Dénakpo M, Ahlonsou G, Ginbo Bedada A, Nsengiyumva C, Kwizera S, Barendegere V, Choi P, Stock S, Jamal L, Azzie G, Kushwaha S, Chen TL, Yip C, Montes I, Zapata F, Sierra S, Villegas Lanau MI, Mendoza Arango MC, Mendoza Restrepo I, Restrepo Giraldo RS, Domini E, Karlo R, Mihanovic J, Youssef M, Elfeki H, Thabet W, Sanad A, Tawfik G, Zaki A, Abdel-Hameed N, Mostafa M, Omar MFW, Ghanem A, Abdallah E, Denewer A, Emara E, Rashad E, Sakr A, Elashry R, Emile S, Khafagy T, Elhamouly S, Elfarargy A, Mamdouh Mohamed A, Saied Nagy G, Esam A, Elwy E, Hammad A, Khallaf S, Ibrahim E, Said Badr A, Moustafa A, Eldosouky Mohammed A, Elgheriany M, Abdelmageed E, Al Raouf EA, Samir Elbanby E, Elmasry M, Morsy Farahat M, Yahya Mansor E, Magdy Hegazy E, Gamal E, Gamal H, Kandil H, Maher Abdelrouf D, Moaty M, Gamal D, El-Sagheer N, Salah M, Magdy S, Salah A, Essam A, Ali A, Badawy M, Ahmed S, Mohamed M, Assal A, Sleem M, Ebidy M, Abd-Elrazek A, Zahran D, Adam N, Nazir M, Hassanein AB, Ismail A, Elsawy A, Mamdouh R, Mabrouk M, Ahmed LAM, Hassab Alnaby M, Magdy E, Abd-Elmawla M, Fahim M, Mowafy B, Ibrahim Mahmoud M, Allam M, Alkelani M, Halim El Gendy N, Saad Aboul-Naga M, Alaa El-Din R, Elgendy AH, Ismail M, Shalaby M, Adel Elsharkawy A, Elsayed Moghazy M, Hesham Elbisomy K, Abdel Gawad Shakshouk H, Hamed MF, Ebidy MM, Abdelkader M, Karkeet M, Ahmed H, Adel I, Omar ME, Ibrahim M, Ghoneim O, Hesham O, Gamal S, Hilal K, Arafa O, Adel Awad S, Salem M, Abdellatif Elsherif F, Elsabbagh N, Aboelsoud MR, Hossam Eldin Fouad Rida A, Hossameldin A, Hany E, Hosny Asar Y, Anwar N, Gadelkarim M, Abdelhady S, Mohamed Morshedy E, Saad R, Soliman N, Salama M, Ezzat E, Mohamed A, Ibrahim A, Fergany A, Mohammed S, Reda A, Allam Y, Saad HA, Abdelfatah A, Fathy AM, El-Sehily A, Abdalmageed Kasem E, Hassan ATA, Mohammed AR, Saad AG, Elfouly Y, Elfouly N, Ibrahim A, Hassaan A, Mohammed MM, Elhoseny G, Magdy M, Abd Elkhalek E, Zakaria Y, Ezzat T, Abo El Dahab A, Kelany M, Arafa S, Mokhtar Mohamed Hassan O, Mohamed Badwi N, Saber Sleem A, Ahmed H, Abdelbadeai K, Abozed Abdullah M, Lokman MAA, Bahar S, Rady Abdelazeam A, Adelshone A, Bin Hasnan M, Zulkifli A, Kamarulzamil SNA, Elhendawy A, Latif A, Bin Adnan A, Shaharuddin S, Haji Abdul Majid AH, Amreia M, Al-Marakby D, Salma M, Ismail MJB, Mohd Basir ER, Mohd Ali CD, Ata AY, Nasr M, Rezq A, Sheta A, Tariq S, Sallam AE, Darwish AKZ, Elmihy S, Elhadry S, Farag A, Hajeh H, Abdelaal A, Aglan A, Zohair A, Essam M, Moussa O, El-Gizawy E, Samy M, Ali S, El Halawany E, Ata A, El Halawany M, Nashat M, Soliman S, Elazab A, Samy M, Abdelaziz MA, Ibrahim K, Ibrahim AM, Gado A, Hantour U, Alm Eldeen E, Loaloa MR, Abouzaid A, Ahmed Bahaa Eldin M, Hashad E, Sroor F, Gamil D, Mahmoud Abdulhakeem E, Zakaria M, Mohamed F, Abubakr M, Ali E, Magdy H, Ramadan MT, Abdelaty Mohamed M, Mansour S, Abdul Aziz Amin H, Rabie Mohamed A, Saami M, Ahmed Reda Elsayed N, Tarek A, Mohy Eldeen Mahmoud S, Magdy El Sayed I, Reda A, Yusuf Shawky M, Mousa Salem M, Alaa El-Din S, Abdullah Soliman N, Talaat M, Alaael-Dein S, Abd Elmoen Elhusseiny A, Abdullah N, Elshaar M, Abdelfatah Ibraheem A, Abdulaziz H, Kamal Ismail M, Hamdy Madkor M, Abdelaty M, Mahmoud Abdel-Kader S, Mohamed Salah O, Eldafrawy M, Zaki Eldeeb A, Mahmoud Eid M, Attia A, Salah El-Dien K, Shwky A, Badenjki MA, Soliman A, Mahmoud Al Attar S, Sayed F, Abdel Sabour F, Azizeldine MG, Shawqi M, Hashim A, Aamer A, Abdelraouf AM, Abdelshakour M, Ibrahim A, Mahmoud B, Ali Mahmoud M, Qenawy M, Rashed AM, Dahy A, Sayed M, Shamsedine AW, Mohamed B, Hasan A, Saad MM, Abdul Bassit K, Khalid Abd El-Latif N, Elzahed N, El Kashash A, Bekhet NM, Hafez S, Gad A, Maher ME, Abd El-Sameea A, Hafez M, Sabe A, Ahmed A, Shahine A, Dawood K, Gaafar S, Husseiny R, Aboelmagd O, Soliman A, Mesbah N, Emadeldin H, Al Meligy A, Bekhet AH, Hasan D, Alhady K, Sabe AK, Elnajjar MA, Aboelella M, Hamsho W, Hassan I, Saad H, Abdelazim G, Mahmoud H, Wael N, Kandil AM, Magdy A, Said Elkholy S, Adel BE, Dabbour K, Elsherbiney S, Mattar O, Khaled AbdRabou A, Aly MYM, Geuoshy A, Elnagar A, Ahmed S, Abdelmotaleb I, Saleh AA, Mohammed Bakry H, Saeed M, Mahmoud S, Tawfik BA, Ismail SA, Zakaria E, Gad MO, Salah Elhelbawy M, Bassem M, Maraie N, Medhat Elhadary N, Semeda N, Rabie Mohamed S, Bakry HM, Essam AA, Tarek D, Ashour K, Elhadad A, Abdel-Aty A, Rakha I, Mamdouh Matter S, Abdelhamed R, Abdelkader O, Hassaan A, Soliman Y, Mohamed A, Ghanem S, Amr Mohamed Farouk S, Ibrahim EM, El-Taher E, Mostafa M, Mahrous Badr MF, Elsemelawy R, El-Sawy A, Bakr A, Al Rafati AAR, Saar S, Reinsoo A, Seyoum N, Worku T, Fitsum A, Tolonen M, Leppäniemi A, Sallinen V, Parmentier B, Peycelon M, Irtan S, Dardenne S, Robert E, Maillot B, Courboin E, Arnaud AP, Hascoet J, Abbo O, Ait Kaci A, Prudhomme T, Ballouhey Q, Grosos C, Fourcade L, Cecilia T, Jean-Francois C, Helene FC, Delforge X, Haraux E, Dousset B, Schiavone R, Gaujoux S, Marret JB, Haffreingue A, Rod J, Renaux-Petel M, Lecompte JF, Bréaud J, Gastaldi P, Taieb C, Claire R, Anis E, Bustangi N, Lopez M, Scalabre A, Grella MG, Mariani A, Podevin G, Schmitt F, Hervieux E, Broch A, Muller C, Bandoh D, Abantanga F, Kyereh M, Asumah H, Appiah EK, Wondoh P, Gyedu A, Dally C, Agbedinu K, Amoah M, Yifieyeh A, Agbedinu K, Owusu F, Amoako-Boateng M, Dayie M, Hagan R, Debrah S, Ohene-Yeboah M, Clegg-Lampety JN, Etwire V, Dakubo J, Essoun S, Bonney W, Glover-Addy H, Osei-Nketiah S, Amoako J, Adu-Aryee N, Appeadu-Mensah W, Bediako-Bowan A, Dedey F, Ekow M, Akatibo E, Yakubu M, Kordorwu HEK, Asare-Bediako K, Tackie E, Aaniana K, Acquah E, Opoku-Agyeman R, Avoka A, Kusi K, Maison K, Gyamfi FE, Naa Barnabas G, Abdul-Latif S, Taah Amoako P, Davor A, Dassah V, Dagoe E, Kwakyeafriyie P, Akoto E, Ackom E, Mensah E, Atkins ET, Coompson CL, Ivros N, Ferousis C, Kalles V, Agalianos C, Kyriazanos I, Barkolias C, Tselos A, Tzikos G, Voulgaris E, Lytras D, Bamicha A, Psarianos K, Stefanopoulos A, Patoulias I, Sfougaris D, Valioulis I, Balalis D, Korkolis D, Manatakis DK, Kyrou G, Karabelias G, Papaskarlatos IA, Konstantina K, Zampitis N, Germanos S, Papailia A, Theodosopoulos T, Gkiokas G, Mitroudi M, Panteli C, Feidantsis T, Farmakis K, Kyziridis D, Ioannidis O, Parpoudi S, Gemenetzis G, Parasyris S, Anthoulakis C, Nikoloudis N, Margaritis M, Aguilera-Arevalo ML, Coyoy-Gaitan O, Rosales J, Tale L, Soley R, Barrios E, Rodriguez STT, Paz Galvez C, Herrera Cruz D, Sanchez Rosenberg G, Matheu A, Cohen DM, Paul M, Charles A, Lam JCY, Yeung MHA, Fok CYJ, Li KHG, Lai ACH, Cheung YHE, Wong HY, Leung KW, Lee TSB, Lam WH, Dao W, Kwok SHW, Chan TYK, Ng YK, Mak TWC, Foo CC, Yang J, Bhatnagar A, Upadhyaya V, Muddebihal U, Dar W, Janardhan KC, Aruldas N, Adella FJ, Rulie AS, Iskandar F, Setiawan J, Evajelista CV, Natalie H, Suyadi A, Gunawan R, Karismaningtyas H, Mata LPS, Andika FFA, Hasanah A, Widiastini TA, Purwaningsih NA, Mukin ADF, Rahmah DF, Nurqistan HD, Arsyad HM, Adhitama N, Jeo WS, Sutandi N, Clarissa A, Gultom PA, Billy M, Haloho A, Johanna N, Lee F, Radin Dorani RMN, Glynn M, Alherz M, Goh W, Shiwani HA, Sproule L, Conlon KC, Bala M, Kedar A, Turati L, Bianco F, Steccanella F, Gallo G, Trompetto M, Clerico G, Papandrea M, Sammarco G, Sacco R, Benevento A, Giavarini L, Giglio MC, Bucci L, Pagano G, Sollazzo V, Peltrini R, Luglio G, Birindelli A, Di Saverio S, Tugnoli G, Paludi MA, Mingrone P, Pata D, Selvaggi F, Selvaggi L, Pellino G, Di Martino N, Curletti G, Aonzo P, Galleano R, Berti S, Francone E, Boni S, Lorenzon L, lo Conte A, Balducci G, Confalonieri G, Pesenti G, Gavagna L, Vasquez G, Targa S, Occhionorelli S, Andreotti D, Pata G, Armellini A, Chiesa D, Aquilino F, Chetta N, Picciariello A, Abdelkhalek M, Belli A, De Franciscis S, Bigaran A, Favero A, Basso SMM, Salusso P, Perino M, Mochet S, Sasia D, Riente F, Migliore M, Merlini D, Basilicò S, Corbellini C, Lazzari V, Macchitella Y, Bonavina L, Angelieri D, Coletta D, Falaschi F, Catani M, Reali C, Malavenda M, Del Basso C, Ribaldi S, Coletti M, Natili A, Depalma N, Iannone I, Antoniozzi A, Rossi D, Gui D, Perrotta G, Ripa M, Giardino FR, Foco M, Vicario E, Coccolini F, Nita GE, Leone N, Bondurri A, Maffioli A, Simioni A, De Boni D, Pasquali S, Goldin E, Vendramin E, Ciccioli E, Tedeschi U, Bortolasi L, Violi P, Campagnaro T, Conci S, Lazzari G, Iacono C, Gulielmi A, Manfreda S, Rinaldi A, Ringressi MN, Brunoni B, Salamone G, Mangiapane M, De Marco P, La Brocca A, Tutino R, Silvestri V, Licari L, Fontana T, Falco N, Cocorullo G, Shalaby M, Sileri P, Arcudi C, Bsisu I, Aljboor K, Abusalem L, Alnusairat A, Qaissieh A, Al-Dakka E, Ababneh A, Halhouli O, Yusufali T, Mohammed H, Lando J, Parker R, Ndegwa W, Jokubauskas M, Gribauskaite J, Kuliavas J, Dulskas A, Samalavicius NE, Jasaitis K, Parseliunas A, Nevieraite V, Montrimaite M, Slapelyte E, Dainius E, Riauka R, Dambrauskas Z, Subocius A, Venclauskas L, Gulbinas A, Bradulskis S, Kasputyte S, Mikuckyte D, Kiudelis M, Jankus T, Petrikenas S, Pažuskis M, Urniežius Z, Vilčinskas M, Banaitis VJ, Gaižauskas V, Grisin E, Mazrimas P, Rackauskas R, Drungilas M, Lagunavicius K, Lipnickas V, Majauskyté D, Jotautas V, Abaliksta T, Uščinas L, Simutis G, Ladukas A, Danys D, Laugzemys E, Mikalauskas S, Zdanyte Sruogiene E, Višinskas P, Žilinskienė R, Dragatas D, Burmistrovas A, Tverskis Z, Vaicius A, Mazelyte R, Zadoroznas A, Kaselis N, Žiubrytė G, Rahantasoa FCFP, Samison LH, Rasoaherinomenjanahary F, Tolotra TEC, Mukuzunga C, Kwatiwani C, Msiska N, Chai FY, Asilah SMD, Syibrah KZ, Chin PX, Salleh A, Riswan NZ, Roslani AC, Chong HY, Aziz NA, Poh KS, Chai CA, Kumar S, Taher MM, Kosai NR, Abdul Aziz DN, Rajan R, Julaihi R, Jethwani DL, Yahaya MT, Nik Abdullah NA, Mathew SW, Chung KJ, Nirumal MK, Ern Tze RG, Wan Ali SAWE, Gan YY, Ting JRS, Sii SSY, Koay KL, Tan YK, Cheah AEZ, Wong CY, Tuan Mat TN, Chow CYN, Har PAL, Der Y, Henry F, Low X, Neo YT, Heng HE, Kong SN, Gan C, Mok YT, Tan YW, Palayan K, Deva Tata M, Cheong YJ, Gunaseelan K, Wan Mohd Nasir WN'A, Yoganathan P, Lee EX, Saw JE, Yeang LJ, Koh PY, Lim SY, Teo SY, Grech N, Magri D, Cassar K, Mizzi C, Falzon M, Shaikh N, Scicluna R, Zammit S, Mizzi S, Brincat SD, Tembo T, Hien Le VT, Grima T, Sammut K, Carabott K, Zarb C, Navarro A, Dimech T, Camilleri GM, Bertuello I, Dalli J, Bonavia K, Corro-Diaz S, Manriquez-Reyes M, Abdelhamid A, Hrora A, Benammi S, Bachri H, Abbouch M, Boukhal K, Bennai RM, Belkouchi A, Jabal MS, Benyaiche C, Vermaas M, Duinhouwer L, Pastora J, Wood G, Merlo MS, Ajao A, Ayandipo O, Lawal T, Abdurrazzaaq A, Alada M, Nasir A, Adeniran J, Habeeb O, Popoola A, Adeyeye A, Adebanjo A, Adesanya O, Adeniyi A, Mendel H, Bello B, Muktar U, Osinowo A, Olajide TO, Oshati O, Ihediwa G, Adenekan B, Nwinee V, Alakaloko F, Elebute O, Lawal A, Bode C, Olugbemi M, Adesina A, Faturoti O, Odutola O, Adebola O, Onuoha C, Taiwo O, Williams O, Balogun F, Ajai O, Oludara M, Njokanma I, Osuoji R, Kache S, Ajah J, Makama J, Adamu A, Baba S, Aliyu M, Aliyu S, Ukwenya Y, Aliyu H, Sholadoye T, Daniyan M, Ogunsua O, Anyanwu LJ, Sheshe A, Mohammad A, Olori S, Mshelbwala P, Odeyemi B, Samson G, Kehinde Timothy O, Ali Samuel S, Ajiboye A, Amole I, Abiola O, Olaolorun A, Veen T, Kanani A, Styles K, Herikstad R, Wiik Larsen J, Søreide JA, Jensen E, Gran M, Aahlin EK, Gaarder T, Monrad-Hansen PW, Næss PA, Lauzikas G, Wiborg J, Holte S, Augestad KM, Banipal GS, Monteleone M, Moe TT, Schultz JK, Nadeem N, Saqlain M, Abbasy J, Alvi AR, Shahzad N, Bhopal KF, Iftikhar Z, Butt MT, ul Razi SA, Ahmed A, Khan Niazi A, Raza I, Baluch F, Raza A, Bani-Sadar A, Adil M, Raza A, Javaid M, Waqar M, Khan MA, Arshad MM, Amjad MA, Al-taher T, Hamdan A, Salman A, Saadeh R, Musleh A, Jaradat D, Abushamleh S, Hanoun S, Abu Qumbos A, Hamarshi A, Taher AA, Qawasmi I, Qurie K, Altarayra M, Ghannam M, Shaheen A, Herebat A, Abdelhaq A, Shalabi A, Abu-toyour M, Asi F, Shamasneh A, Atiyeh A, Mustafa M, Zaa'treh R, Dabboor M, Alaloul E, Baraka H, Meqbil J, Al-Buhaisi A, Elshami M, Afana S, Jaber S, Alyacoubi S, Abuowda Y, Idress T, Abuqwaider E, Al-saqqa S, Bowabsak A, El Jamassi A, Hasanain D, Al-Farram H, Salah M, Firwana A, Hamdan M, Awad I, Ashour A, Al Barrawi FE, Alkhatib A, Al-Faqawi M, Fares M, Elmashala A, Adawi M, Adawi I, Khreishi R, Khreishi R, Ashour A, Ghaben A, Machain Vega GM, Cardozo JT, Roche MO, Pertersen Servin GR, Segovia Lohse HA, Páez Lopez LI, Cardozo RAM, Espinoza F, Pérez Rojas AD, Sanchez D, Samaniego CS, Guevara Torres S, Calua AC, Razuri C, Ortiz N, Rodriguez X, Carrasco N, Saravia F, Shibao Miyasato H, Valcarcel-Saldaña M, Bermúdez YEA, Carpio J, Ruiz Panez W, Toribio Orbegozo PA, Guzmán Dueñas C, Turpo Espinoza K, Sandoval Barrantes AM, Chungui Bravo JA, Fuentes-Rivera L, Fernández C, Málaga B, Ye J, Velasquez R, Salcedo J, Contreras-Vergara AL, Vergara Mejia AG, Gonzales Montejo MS, Escalante Salas MDC, Alcca Ticona W, Vargas M, Manrique Sila GC, Mas R, del Pilar Paucar A, Román Velásquez AJ, Robledo-Rabanal A, Solis LAZ, Turpo Espinoza K, Hamasaki Hamaguchi JL, Florez Farfan ES, Madrid Barrientos LA, Herrera Matta JJ, Mora JJV, Redota MAP, Roxas MF, Maño MJB, Parreno-Sacdalan MD, Almanon CL, Walędziak M, Roszkowski R, Janik M, Lasek A, Radkowiak D, Rubinkiewicz M, Fernandes C, Costa-Maia J, Melo R, Muntean L, Mironescu AS, Vida LC, Popa M, Mircea H, Vartic M, Diaconescu B, Bratu MR, Negoi I, Beuran M, Ciubotaru C, Uzabumwana N, Duhoranenayo D, Jovine E, Zanini N, Landolfo G, Aljiffry M, Idris F, Alghamdi MSA, Maghrabi A, Altaf A, Alkaaki A, Khoja A, Nawawi A, Turkustani S, Khalifah E, Albiety A, Sahel S, Alshareef R, Najjar M, Alzahrani A, Alghamdi A, Alhazmi W, Al Saied G, Alamoudi M, Riaz MM, Hassanain M, Alhassan B, Altamimi A, Alyahya R, Al Subaie N, Al Bastawis F, Altamimi A, Nouh T, Khan R, Radojkovic M, Jeremic L, Nestorovic M, Law JH, Tan KSK, Tan RCK, Tan JK, Joel LWL, Chan XW, Leong FQH, Chong CS, Koh S, Lee KY, Lee KC, Pluke K, Dedekind B, Nashidengo P, Hampton MI, Joosten J, Sobnach S, Roodt L, Sander A, Pape J, Maistry N, Ndwambi P, Kinandu K, Tun M, Du Toit F, Ellison Q, Burger S, Grobler DC, Khulu LB, Moore R, Jennings V, Leusink A, Kariem N, Gouws J, Chu K, Bougard H, Noor F, Dell A, Van Straten S, Khamajeet A, Tshisola SK, Kabongo K, Kong V, Moodley Y, Anderson F, Madiba T, du Plooy F, Hartford L, Chilton G, Karjiker P, Mabitsela ME, Ndlovu SR, Badicel M, Jaich R, Ruiz-Tovar J, Garcia-Florez L, Otero-Díez JL, Ramos Pérez V, Aguado Suárez N, Minguez García J, Corral Moreno S, Collado MV, Jiménez Carneros V, García Septiem J, Gonzalez M, Picardo A, Esteban E, Ferrero E, Espin-Basany E, Blanco-Colino R, Andriola V, Solar García L, Contreras E, García Bernardo C, Pagnozzi J, Sanz S, Miyar de León A, Dorismé A, Rodicio J, Suarez A, Stuva J, Diaz Vico T, Fernandez-Vega L, Soldevila-Verdeguer C, Sena-Ruiz F, Pujol-Cano N, Diaz-Jover P, Garcia-Perez JM, Segura-Sampedro JJ, Pineño-Flores C, Ambrona-Zafra D, Craus-Miguel A, Jimenez-Morillas P, Mazzella A, Jayathilake AB, Thalgaspitiya SPB, Wijayarathna LS, Wimalge PMSN, Sanni HA, Okenabirhie O, Homeida A, Younis A, Omer OA, Abdulaziz M, Mussad A, Adam A, Björklund I, Ahlqvist S, Thorell A, Wogensen F, Sokratous A, Breistrand M, Thorarinsdottir H, Sigurdadottir J, Nikberg M, Chabok A, Hjertberg M, Elbe P, Saraste D, Rutkowski W, Forlin L, Niska K, Sund M, Oswald D, Peros G, Bluelle R, Reinisch K, Frey D, Palma A, Raptis DA, Zumbühl L, Zuber M, Schmid R, Werder G, Nocito A, Gerosa A, Mahanty S, Widmer LW, Müller J, Gübeli A, Zuk G, Gulcicek OB, Vartanoglu T, Kose E, Karahan SR, Aydin MC, Sahbaz NA, Halicioglu I, Alis H, Sapci I, Adiyaman C, Pektaş AM, Cengiz TB, Tansoker I, Işler V, Cevik M, Mutlu D, Ozben V, Ozmen BB, Bayram S, Yolcu S, Kobal BB, Toto ÖF, Çakaloğlu HC, Karabulut K, Mutlu V, Ozkan BB, Celik S, Semiz A, Bodur S, Gül E, Murutoglu B, Yildirim R, Baki BE, Arslan E, Ulusahin M, Guner A, Tomas K, Walker N, Shrimanker N, Cole S, Breslin R, Srinivasan R, Elshaer M, Hunter K, Al-Bahrani A, Liew I, Mairs NG, Rocke A, Dick L, Qureshi M, Chowdhury D, Wright N, Skerritt C, Kufeji D, Ho A, Dissanayake T, Tennakoon A, Ali W, Lim SJ, Tan C, O'Neill S, Jones C, Knight S, Nassif D, Sharma A, Warren O, White R, Mehdi A, Post N, Kalakouti E, Dashnyam E, Stourton F, Mykoniatis I, Currow C, Wong F, Gupta A, Shatkar V, Luck J, Kadiwar S, Smedley A, Wakefield R, Herrod P, Blackwell J, Lund J, Cohen F, Bandi A, Giuliani S, Bond-Smith G, Pezas T, Farhangmehr N, Urbonas T, Perenyei M, Ireland P, Blencowe N, Bowling K, Bunting D, Longstaff L, Keogh K, Jeon H, Iqbal MR, Khosla S, Jeffery A, Perera J, Ibrahem AA, Alhammali T, Salama Y, Oram S, Kidd T, Cullen F, Owen C, Wilson M, Chiu S, Sarafilovic H, Ploski J, Evans E, Abbas A, Kamya S, Ishak N, Bisset C, Andress C, Chin YR, Patel P, Evans D, Haslegrave A, Boggon A, Laurie K, Connor K, Mann T, Mansuri A, Davies R, Griffiths E, Shahbaz AR, Eng C, Din F, L'Heveder A, Park EHG, Ravishankar R, McIntosh K, Yau JD, Chan L, McGarvie S, Tang L, Lim H, Yap S, Park J, Ng ZH, Mirza S, Ang YL, Walls L, Roy C, Paterson-Brown S, Camilleri-Brennan J, Mclean K, D'Souza MS, Pronin S, Henshall DE, Ter EZ, Fouad D, Minocha A, English W, Morgan C, Townsend D, Maciejec L, Mahdi S, Akpenyi O, Hall E, Caydiid H, Rob Z, Abbott T, Torrance HD, Johnston R, Gani MA, Gravante G, Rajmohan S, Majid K, Dindyal S, Smith C, Palliyil M, Patel S, Nicholson L, Harvey N, Baillie K, Shillito S, Kershaw S, Bamford R, Orton P, Reunis E, Tyler R, Soon WC, Jama GM, Dhillon D, Patel K, Nanthakumaran S, Heard R, Chen KY, Barmayehvar B, Datta U, Kamarajah SK, Karandikar S, Iftekhar Tani S, Monaghan E, Donnelly P, Walker M, Parakh J, Blacker S, Kaul A, Paramasivan A, Farag S, Nessa A, Awadallah S, Lim J, Chean Khun Ng J, Kiran RP, Murray A, Etchill E, Dasari M, Puyana J, Haddad N, Zielinski M, Choudhry A, Caliman C, Beamon M, Duane T, Swaroop M, Myers J, Deal R, Schadde E, Hemmila M, Napolitano L, To K, Makupe A, Musowoya J, van der Naald N, Kumwenda D, Reece-Smith A, Otten K, Verbeek A, Prins M, Baquero Suarez AA, Balmaceda R, Deane C, Dijan E, Elfiky M, Koskenvuo L, Thollot A, Limoges B, Capito C, Alexandre C, Kotobi H, Leroux J, Pinnagoda K, Henric N, Azzis O, Rosello O, Francois P, Etienne S, Buisson P, Hmila S, Clegg-Lamptey JN, Imoro O, Abem OE, Papageorgiou D, Soulou V, Asturias S, Peña L, O'Connor DB, Luc AR, Russo AA, Ruzzenente A, Taddei A, Cona C, Bottini C, Pascale G, Rotunno G, Solaini L, Pascale MM, Notarnicola M, Corbellino M, Sacco M, Ubiali P, Cautiero R, Bocchetti T, Muzio E, Guglielmo V, Morandi E, Mao P, de Luca E, Ali FM, Žilinskas J, Strupas K, Kondrotas P, Baltrunas R, Kutkevicius J, Ignatavicius P, Tan CL, Siaw JY, Yam SY, Wilson L, Aziz MRA, Bondin J, Zorrilla CD, Majbar A, Sale D, Abdullahi L, Osagie O, Faboya O, Fatuga A, Taiwo A, Nwabuoku E, Bliksøen M, Khan ZA, Coronel J, Miranda C, Vasquez I, Helguero-Santin LM, Rickard J, Adedeji A, Alqahtani S, Rath M, Van Niekerk M, Koto MZ, Matos-Puig R, Israelsson L, Schuetz T, Yuksek MA, Mericliler M, Ulusahin M, Wolf B, Fairfield C, Yong GL, Whitehurst K, Redgrave N, Musyoka CK, Olivier J, Lee K, Cox M, Farhan-Alanie MMH, Callan R, Chibuye C, Ali THA, Rekhis S, Rommaneh M, Sam ZH, Pugliesi TB, Pardo G, Blanco R. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis 2018; 18:516-525. [PMID: 29452941 PMCID: PMC5910057 DOI: 10.1016/s1473-3099(18)30101-4] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/06/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. METHODS This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. FINDINGS Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). INTERPRETATION Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. FUNDING DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.
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Mpirimbanyi C, Nyirimodoka A, Lin Y, Hedt-Gauthier BL, Odhiambo J, Nkurunziza T, Havens JM, Omondi J, Rwamasirabo E, Ntirenganya F, Toma G, Mubiligi J, Bayitondere S, Riviello R. Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes. BMC Surg 2017; 17:121. [PMID: 29191200 PMCID: PMC5709982 DOI: 10.1186/s12893-017-0323-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 11/21/2017] [Indexed: 12/25/2022] Open
Abstract
Background Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda. Methods This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes. Results In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15–60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died. Conclusion While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.
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Affiliation(s)
- Christophe Mpirimbanyi
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Alexandre Nyirimodoka
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Yihan Lin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Joaquim M Havens
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Jack Omondi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Ministry of Health, Kigali, Rwanda
| | | | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Gabriel Toma
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Joel Mubiligi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
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Abahuje E, Munyaneza R, Riviello R, Ntirenganya F. Assessment of hemodynamic response to fluid resuscitation of patients with intra-abdominal sepsis in low- and middle-income countries. J Surg Res 2017; 218:162-166. [PMID: 28985844 DOI: 10.1016/j.jss.2017.05.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 04/25/2017] [Accepted: 05/18/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with intra-abdominal infections need to achieve adequate hemodynamic status before being taken to the operating room. Multiple parameters (urinary output [UOP], vital signs, inferior vena cava collapsibility index, and central venous pressure) may be used to assess hemodynamic response to fluid resuscitation, but the options are few in limited-resource settings. This study aimed at assessing if a bedside-performed ultrasound to assess the inferior vena cava collapsibility index is superior to UOP in assessing hemodynamic response to fluid resuscitation. METHODS All adult patients presenting to a tertiary referral hospital in the capital city of Rwanda with intra-abdominal infection requiring intravenous fluid (IVF) resuscitation before operation were included in this study. Before IVF administration, the baseline inferior vena cava collapsibility index (IVC-CI) and vital parameters were recorded. After initiation of IVF resuscitation, serial measurements of IVC-CI and UOP were recorded every 2 h until the decision was made to take the patient to the operating room. RESULTS Twenty-four patients were enrolled. The mean duration of symptoms was 4.7 days. Four patients (16%) had altered mental status as a presenting symptom. Half of all patients had generalized peritonitis due to gangrenous bowel as the primary diagnosis (n = 12). The mean difference between time of hemodynamic response based on IVC-CI versus UOP was 2 h (P < 0.001). CONCLUSIONS Measurement of the IVC-CI can provide early detection of hemodynamic response to fluid therapy in patients with intra-abdominal infection with spontaneous breathing compared to UOP. Future research should utilize this parameter in the preoperative management of hemodynamically unstable patients.
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Affiliation(s)
- Egide Abahuje
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda.
| | - Robert Munyaneza
- Department of Surgery, Butare University Teaching Hospital, Huye City, Rwanda
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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Jenny HE, Abahuje E, Maswime S, Tansley G, Fallah P, Harrop T, Kember A, Kilyewala C, Ekenze S, Diehl T, Awasano DA, Rakotomalala JH, Jammeh S, Nyirigira G, Silverstein A, Williams D, Kirunda S, Knapp G, Balumuka DD, Tansley G, Wong A, Ogundele J, Nasir A, Pemberton J, Pivnick L, Ekenze S, Knapp G, Eliacin HC, LeBlanc D, Ntirenganya F, Usoro N, Nasir A, Robert DJC, Bowder A, Ward L, Louis MLJ, Rickard J, Buchmann E, Bernstein M, O’Flynn E, Howard A, Jani P, Bekele A, Cameron B, Coleman J, Borazjani A, Scott H, O’Brien L, Butler M, Okere M, Wells J, MacRitchie S, Isaac A, Lipnick M, O’Hara N, Ozgediz D, Dubowitz G, Nakanwagi A, Tumukunde J, Modekwe V, Ajuzieogu O, Ezomike U, Sanusi J, Malemo LK, Deckelbaum D, Bracco D, Diehl K, Kwiratwiwe C, Habamungu P, Razek T, Bleicher J, Liko O, Poenaru D, Randianandrasana G, Eeson G, Sanyang B, Badjie A, Eckfeldt M, Eckfeldt C, Brauer D, Just J, Twagirumugabe T, Chavarri AC, Gakwaya M, Lule J, Shrime MG, Howard A, Kohler J, Galukande M, Alenyo R, Makumbi T, Nansubuga M, Wesonga A, Yiga J, Kuteesa J, Anena B, Ernest A, Hoogerboord M, Traynor R, Galiwango G, Alenyo R, Lacob K, Wilson M, Zwolski S, Zeki DA, Acharya S, Nwosu D, Bamigbola K, Abdur-Rahman L, Gobir A, Adeniran J, Poenaru D, Beyene MD, Neufeld V, Cameron B, Sasson L, Tamir A, Houri S, Goldman B, Ajuzieogu O, Ezomike U, Nwankwo E, Sanusi J, Onuh A, Traynor R, Lasante Z, Outhay M, Edmond C, Evans C, Ng-Kamstra J, Rouhani S, Marsh R, Sacier L, Wren S, Poenaru D, Riviello R, Ntakiyiruta G, Akpabio E, Japhet E, Osakwe O, Edentekhe T, Inyama M, Olukoya H, Ekanem E, Depena-Gray B, Abdur-Rahman L, Oyekunle A, Adesiyun O, Adegboye M, Olanrewaju M, Alonge D, Bamigbola K, Obasa T, Adesiyun A, Biliaminu S, Bolaji B, Adeniran J. 2016 Bethune Round Table Abstracts. Can J Surg 2016; 59:S65-74. [PMID: 27240291 DOI: 10.1503/cjs.007016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Ntirenganya F, Petroze RT, Kamara TB, Groen RS, Kushner AL, Kyamanywa P, Calland JF, Kingham TP. Prevalence of breast masses and barriers to care: results from a population-based survey in Rwanda and Sierra Leone. J Surg Oncol 2014; 110:903-6. [PMID: 25088235 DOI: 10.1002/jso.23726] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/18/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Breast cancer incidence may be increasing in low- and middle-income countries (LMIC). This study estimates the prevalence of breast masses in Rwanda (RW) and Sierra Leone (SL) and identifies barriers to care for women with breast masses. only. METHODS Data were collected from households in RW and SL using Surgeons Overseas Assessment of Surgical Need (SOSAS), a cross-sectional, randomized, cluster-based population survey designed to identify surgical conditions. Data regarding breast masses and barriers to care in women with breast masses were analyzed. RESULTS 3,469 households (1,626 RW; 1,843 SL) were surveyed and 6,820 persons (3,175 RW; 3,645 SL) interviewed. Breast mass prevalence was 3.3% (SL) and 4.6% (RW). Overall, 93.8% of masses were in women, with 49.1% (SL) and 86.1% (RW) in women >30 years. 73.7% (SL) and 92.4% (RW) of women reported no disability; this was their primary reason for not seeking medical attention. Overall, 36.8% of women who reported masses consulted traditional healers only. CONCLUSIONS For women in RW and SL, minimal education, poverty, and reliance on traditional healers are barriers to medical care for breast masses. Public health programs to increase awareness and decrease barriers are necessary to lower breast cancer mortality rates in low- and middle-income countries (LMIC).
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Affiliation(s)
- Faustin Ntirenganya
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda; Faculty of Medicine, National University of Rwanda, Rwanda
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Mody GN, Nduaguba A, Ntirenganya F, Riviello R. Characteristics and presentation of patients with breast cancer in Rwanda. Am J Surg 2013; 205:409-13. [DOI: 10.1016/j.amjsurg.2013.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 12/26/2012] [Accepted: 01/03/2013] [Indexed: 11/30/2022]
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