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Kaimila B, Yano Y, Mulima G, Chen Y, Kajombo C, Salima A, Khan S, Gopal S, Dawsey SM, Abnet CC. Poor oral health and the risk of esophageal squamous cell carcinoma in Malawi. Int J Cancer 2024; 154:1587-1595. [PMID: 38194606 DOI: 10.1002/ijc.34829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/25/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024]
Abstract
Esophageal squamous cell carcinoma (ESCC) is the second most common cancer in Malawi. Risk factors for this cancer in Malawi are poorly understood. Poor oral health has previously been linked to increased ESCC risk in other high-incidence regions, including parts of Eastern and Southern Africa. We assessed the relationship between oral health and ESCC risk in a sex, age and location frequency-matched case-control study based at two hospitals in Lilongwe, Malawi from 2017 to 2020. Trained interviewers used a structured questionnaire and direct observation to collect data on demographics; behaviors; oral hygiene habits; the sum of decayed, missing or filled teeth (DMFT score); oral mucosa status; lip depigmentation and dental fluorosis via a visual scale. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI), adjusted for known and suspected ESCC risk factors. During the study period, 300 cases and 300 controls were enrolled. Subjects in the highest tertile of DMFT score (≥7) had an increased risk of ESCC with an adjusted OR of 1.96 (95% CI: 1.16-3.36) compared to those with a DMFT score of 0. Severe dental fluorosis was associated with a statistically nonsignificant increased risk of ESCC (adjusted OR = 2.24, 95% CI: 0.97-5.49) compared to individuals with no fluorosis. Associations with oral mucosa status, lip depigmentation and toothbrushing method and frequency were mostly null or uncertain. Poor oral health, indicated by a higher DMFT score, was associated with increased ESCC risk in Malawi. Dental fluorosis is another possible risk factor in this population, but further evaluation is necessary to clarify any effects of fluorosis on ESCC risk.
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Affiliation(s)
- Bongani Kaimila
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Yukiko Yano
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | | | - Yingxi Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | | | - Ande Salima
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Shiraz Khan
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA
| | - Sanford M Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Christian C Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
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Gjerde H, Huestis MA, Mulima G, Kajombo C, Sundet M, Pechansky F. Recommendations for effective collaboration and capacity building in epidemiological studies on the effect of alcohol and drug use on traffic safety in low- and middle-income countries. Traffic Inj Prev 2024; 25:313-321. [PMID: 38426896 DOI: 10.1080/15389588.2024.2316720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Alcohol or drug impairment is a major risk factor for road traffic crashes, and studies on this issue are essential to provide evidence-based data for policymakers. In low- and middle-income countries (LMICs), such studies are often conducted in partnership with one or more organizations in high-income countries (HICs). The aim of this article is to provide recommendations for improving project planning and decision-making processes in epidemiological studies on alcohol, drug and traffic safety in LMICs involving HICs. METHODS We searched Pubmed, Google Scholar, and Google Search for articles and reports in English about lessons learned when conducting collaborative research in LMIC as well as papers presenting recommendations for effective research collaboration with partners in LMICs. RESULTS Based on the search results, we selected 200 papers for full text examination. Few were related to studies on the effect of alcohol or drug use on road traffic safety. However, several conclusions and recommendations from other studies were found to be relevant. We combined the findings with our own experience in a narrative review. We also present a checklist for risk and quality assessment. CONCLUSIONS Many papers presented similar recommendations, which included the importance of addressing local needs, ensuring adequate resources, local project ownership and leadership, establishing strong partnerships among all involved stakeholders, promoting shared decision-making and planning, and implementing strategies to translate research findings into policy, practice, and publications. It is also important to avoid HIC bias, which prioritizes the interests or perspectives of HICs over those of LMICs.
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Affiliation(s)
- Hallvard Gjerde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- International Council on Alcohol, Drugs and Traffic Safety (ICADTS)
| | - Marilyn A Huestis
- Institute of Emerging Health Professions, Thomas Jefferson University, Severna Park, Maryland
| | | | | | - Mads Sundet
- Centre for Treatment of Rheumatic and Musculoskeletal Disease (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Flavio Pechansky
- International Council on Alcohol, Drugs and Traffic Safety (ICADTS)
- Center for Drug and Alcohol Research, Hospital de Clinicas of Porto Alegre, Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Van Loon K, Mmbaga EJ, Mushi BP, Selekwa M, Mwanga A, Akoko LO, Mwaiselage J, Mosha I, Ng DL, Wu W, Silverstein J, Mulima G, Kaimila B, Gopal S, Snell JM, Benz SC, Vaske C, Sanborn Z, Sedgewick AJ, Radenbaugh A, Newton Y, Collisson EA. A Genomic Analysis of Esophageal Squamous Cell Carcinoma in Eastern Africa. Cancer Epidemiol Biomarkers Prev 2023; 32:1411-1420. [PMID: 37505926 DOI: 10.1158/1055-9965.epi-22-0775] [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] [Received: 07/12/2022] [Revised: 04/19/2023] [Accepted: 07/26/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Esophageal squamous cell carcinoma (ESCC) comprises 90% of all esophageal cancer cases globally and is the most common histology in low-resource settings. Eastern Africa has a disproportionately high incidence of ESCC. METHODS We describe the genomic profiles of 61 ESCC cases from Tanzania and compare them to profiles from an existing cohort of ESCC cases from Malawi. We also provide a comparison to ESCC tumors in The Cancer Genome Atlas (TCGA). RESULTS We observed substantial transcriptional overlap with other squamous histologies via comparison with TCGA PanCan dataset. DNA analysis revealed known mutational patterns, both genome-wide as well as in genes known to be commonly mutated in ESCC. TP53 mutations were the most common somatic mutation in tumors from both Tanzania and Malawi but were detected at lower frequencies than previously reported in ESCC cases from other settings. In a combined analysis, two unique transcriptional clusters were identified: a proliferative/epithelial cluster and an invasive/migrative/mesenchymal cluster. Mutational signature analysis of the Tanzanian cohort revealed common signatures associated with aging and cytidine deaminase activity (APOBEC) and an absence of signature 29, which was previously reported in the Malawi cohort. CONCLUSIONS This study defines the molecular characteristics of ESCC in Tanzania, and enriches the Eastern African dataset, with findings of overall similarities but also some heterogeneity across two unique sites. IMPACT Despite a high burden of ESCC in Eastern Africa, investigations into the genomics in this region are nascent. This represents the largest comprehensive genomic analysis ESCC from sub-Saharan Africa to date.
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Affiliation(s)
- Katherine Van Loon
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Elia J Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Beatrice P Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ally Mwanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Larry O Akoko
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Dianna L Ng
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Wei Wu
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Jordyn Silverstein
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | | | | | - Satish Gopal
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina, Chapel Hill, North Carolina
| | - Jeff M Snell
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | - Zack Sanborn
- NantOmics/NantHealth, Inc., El Segundo, California
| | | | | | - Yulia Newton
- NantOmics/NantHealth, Inc., El Segundo, California
| | - Eric A Collisson
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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Kaimila B, Chen Y, Mulima G, Kajombo C, Salima A, Yano Y, Gopal S, Dawsey SM, Abnet CC. Survival After Diagnosis of Esophageal Squamous Cell Carcinoma in Malawi. JCO Glob Oncol 2023; 9:e2300173. [PMID: 37944090 PMCID: PMC10645405 DOI: 10.1200/go.23.00173] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/07/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE Esophageal cancer (EC) is the second most common cancer in Malawi, with esophageal squamous cell carcinoma (ESCC) representing >90% of all ECs. Despite significant morbidity and mortality, little is known about disease outcomes. In this study, we assess survival after ESCC diagnosis in Malawi. METHODS We report on ESCC cases enrolled in a case-control study at Kamuzu Central Hospital in Lilongwe from August 2017 to April 2020. Suspected cases completed a questionnaire interview; provided blood, urine, and saliva specimens; and underwent a tumor biopsy for histologic confirmation. Cases were followed up by phone biweekly from enrollment to the study end date (December 31, 2020), date of death, or loss to follow-up. Survival was assessed using Kaplan-Meier analysis with the log-rank test. We also examined associations between treatment and ESCC mortality using Cox regression models. RESULTS There were 300 patients with ESCC enrolled in this study, of whom 290 (97%) had known vital status at the end of follow-up and 10 (3%) were lost to follow-up. Among the 290 patients, 282 (97%) died during follow-up. The median age at enrollment was 55 years (IQR, 48-66), and the median time to death was 106 days (95% CI, 92 to 127). The 1-year, 2-year, and 3-year survival rates were 11% (95% CI, 8 to 15), 3% (95% CI, 1 to 6), and 0.9% (95% CI, 0.8 to 4), respectively. Palliative chemotherapy significantly improved the overall survival of patients with ESCC (Plog-rank = .038) and was significantly associated with reduced mortality (adjusted hazard ratio, 0.71 [95% CI, 0.51 to 0.99]). No significant association was observed between tobacco use, alcohol consumption, or HIV status and mortality. CONCLUSION Survival after diagnosis of ESCC was poor in Malawi. Although palliative chemotherapy was associated with improved survival, prevention and earlier detection remain key priorities to improve ESCC mortality at a population level.
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Affiliation(s)
| | - Yingxi Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | | | | | | | - Yukiko Yano
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Sanford M. Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Christian C. Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
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Nomburg J, Bullman S, Nasrollahzadeh D, Collisson EA, Abedi-Ardekani B, Akoko LO, Atkins JR, Buckle GC, Gopal S, Hu N, Kaimila B, Khoshnia M, Malekzadeh R, Menya D, Mmbaga BT, Moody S, Mulima G, Mushi BP, Mwaiselage J, Mwanga A, Newton Y, Ng DL, Radenbaugh A, Rwakatema DS, Selekwa M, Schüz J, Taylor PR, Vaske C, Goldstein A, Stratton MR, McCormack V, Brennan P, DeCaprio JA, Meyerson M, Mmbaga EJ, Van Loon K. An international report on bacterial communities in esophageal squamous cell carcinoma. Int J Cancer 2022; 151:1947-1959. [PMID: 35837755 DOI: 10.1002/ijc.34212] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/23/2022] [Accepted: 04/11/2022] [Indexed: 11/09/2022]
Abstract
The incidence of esophageal squamous cell carcinoma (ESCC) is disproportionately high in the eastern corridor of Africa and parts of Asia. Emerging research has identified a potential association between poor oral health and ESCC. One possible link between poor oral health and ESCC involves the alteration of the microbiome. We performed an integrated analysis of four independent sequencing efforts of ESCC tumors from patients from high- and low-incidence regions of the world. Using whole genome sequencing (WGS) and RNA sequencing (RNAseq) of ESCC tumors from 61 patients in Tanzania, we identified a community of bacteria, including members of the genera Fusobacterium, Selenomonas, Prevotella, Streptococcus, Porphyromonas, Veillonella and Campylobacter, present at high abundance in ESCC tumors. We then characterized the microbiome of 238 ESCC tumor specimens collected in two additional independent sequencing efforts consisting of patients from other high-ESCC incidence regions (Tanzania, Malawi, Kenya, Iran, China). This analysis revealed similar ESCC-associated bacterial communities in these cancers. Because these genera are traditionally considered members of the oral microbiota, we next explored whether there was a relationship between the synchronous saliva and tumor microbiomes of ESCC patients in Tanzania. Comparative analyses revealed that paired saliva and tumor microbiomes were significantly similar with a specific enrichment of Fusobacterium and Prevotella in the tumor microbiome. Together, these data indicate that cancer-associated oral bacteria are associated with ESCC tumors at the time of diagnosis and support a model in which oral bacteria are present in high abundance in both saliva and tumors of some ESCC patients.
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Affiliation(s)
- Jason Nomburg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Program in Virology, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Bullman
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Dariush Nasrollahzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
- International Agency for Research on Cancer (IARC), Genomic Epidemiology Branch, Lyon, France
| | - Eric A Collisson
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, California, USA
- Division of Hematology/Oncology, Department of Medicine, UCSF, San Francisco, California, USA
| | - Behnoush Abedi-Ardekani
- International Agency for Research on Cancer (IARC), Genomic Epidemiology Branch, Lyon, France
| | - Larry O Akoko
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joshua R Atkins
- International Agency for Research on Cancer (IARC), Genomic Epidemiology Branch, Lyon, France
| | - Geoffrey C Buckle
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, California, USA
- Division of Hematology/Oncology, Department of Medicine, UCSF, San Francisco, California, USA
| | - Satish Gopal
- University of North Carolina (UNC), Chapel Hill, North Carolina, USA
| | - Nan Hu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Masoud Khoshnia
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Reza Malekzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Diana Menya
- School of Public Health, Moi University, Eldoret, Kenya
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sarah Moody
- The Cancer, Ageing and Somatic Mutation Programme, Wellcome Trust Sanger Institute, Cambridgeshire, UK
| | | | - Beatrice P Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Ally Mwanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Yulia Newton
- NantOmics/NantHealth, Inc., El Segundo, California, USA
| | - Dianna L Ng
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Pathology, UCSF, San Francisco, California, USA
| | | | - Deogratias S Rwakatema
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joachim Schüz
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Philip R Taylor
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Charles Vaske
- NantOmics/NantHealth, Inc., El Segundo, California, USA
| | - Alisa Goldstein
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Michael R Stratton
- The Cancer, Ageing and Somatic Mutation Programme, Wellcome Trust Sanger Institute, Cambridgeshire, UK
| | - Valerie McCormack
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer (IARC), Genomic Epidemiology Branch, Lyon, France
| | - James A DeCaprio
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Program in Virology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Meyerson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Genetics, Harvard Medical School, Boston, Massachusetts, USA
| | - Elia J Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, California, USA
- Division of Hematology/Oncology, Department of Medicine, UCSF, San Francisco, California, USA
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Mulima G, Lie SA, Charles A, Hanif AB, Varela CG, Banza LN, Young S. Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study. Malawi Med J 2022; 34:152-156. [PMID: 36406102 PMCID: PMC9641605 DOI: 10.4314/mmj.v34i3.2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.
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Affiliation(s)
- Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Stein Atle Lie
- The Norwegian Arthroplasty Registry, Haukeland University Hospital, Bergen, Norway
| | - Anthony Charles
- Department of Surgery, University of North Carolina, 4008 Burnett Womack Bldg, CB 7050, Chapel Hill, NC, 27599 USA
| | - Asma Bilal Hanif
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Carlos G Varela
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Leonard N Banza
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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Williams BM, Mulima G, Charles A. Chest Trauma Management in Low- and Middle-Income Countries. Thorac Surg Clin 2022; 32:329-336. [PMID: 35961741 DOI: 10.1016/j.thorsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.
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Affiliation(s)
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina-Chapel Hill; Kamuzu Central Hospital, Lilongwe, Malawi.
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Kaimila B, Mulima G, Kajombo C, Salima A, Nietschke P, Pritchett N, Chen Y, Murphy G, Dawsey SM, Gopal S, Phiri KS, Abnet CC. Tobacco and other risk factors for esophageal squamous cell carcinoma in Lilongwe Malawi: Results from the Lilongwe esophageal cancer case: Control study. PLOS Glob Public Health 2022; 2:e0000135. [PMID: 36962303 PMCID: PMC10021825 DOI: 10.1371/journal.pgph.0000135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 05/11/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Esophageal cancer is the second commonest cancer in Malawi, and 95% of all cases are esophageal squamous cell carcinoma (ESCC). Very little is known about the epidemiology of ESCC in Malawi including risk factors. The main objective of the study was to evaluate and describe risk factors of ESCC in Malawi. METHODS We conducted a case-control study from 2017 to 2020 at two hospitals in Lilongwe, Malawi and consenting adults were eligible for inclusion. Endoscopy was conducted on all cases and biopsies were obtained for histological confirmation. Controls were selected from patients or their guardians in orthopedic, dental and ophthalmology wards and they were frequency matched by sex, age, and region of origin to cases. An electronic structured questionnaire was delivered by a trained interviewer. Multivariate conditional logistic regression models were used to assess the associations between subject characteristics, habits, and medical history and risk of ESCC. RESULTS During the study period, 300 cases and 300 controls were enrolled into the study. Median age of cases and controls was 56 years and 62% of the cases were male. Among cases, 30% were ever cigarette smokers as were 22% of controls. Smoking cigarettes had an adjusted odds ratio of 2.4 (95% CI 1.4-4.2 p = 0.003). HIV+ status was present in 11% of cases and 4% controls, which resulted in an adjusted odds ratio was 4.0 (95% CI 1.8-9.0 p = 0.001). Drinking hot tea was associated with an adjusted odd ratio of 2.9 (95% CI 1.3-6.3 p = 0.007). Mold on stored grain has an adjusted odd ratio of 1.6 (95% CI 1.1-2.5 p = 0.021). CONCLUSION Reducing smoking cigarettes, consumption of scalding hot tea, and consumption of contaminated grain, could potentially help reduce the burden of ESCC in Malawi. Further investigation of the association between HIV status and ESCC are warranted.
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Affiliation(s)
- Bongani Kaimila
- UNC Project, Department of Cancer Research, Lilongwe, Malawi
| | - Gift Mulima
- Kamuzu Central Hospital, Department of Surgery, Lilongwe, Malawi
| | - Chifundo Kajombo
- Kamuzu Central Hospital, Department of Surgery, Lilongwe, Malawi
| | - Ande Salima
- UNC Project, Department of Cancer Research, Lilongwe, Malawi
| | - Peter Nietschke
- St. Gabriel Hospital, Department of Medicine, Lilongwe, Malawi
| | - Natalie Pritchett
- National Cancer Institute, Department of Cancer Epidemiology and Genetics, Metabolic Epidemiology Branch, Rockville, Maryland, United States of America
| | - Yingxi Chen
- National Cancer Institute, Department of Cancer Epidemiology and Genetics, Metabolic Epidemiology Branch, Rockville, Maryland, United States of America
| | - Gwen Murphy
- National Cancer Institute, Department of Cancer Epidemiology and Genetics, Metabolic Epidemiology Branch, Rockville, Maryland, United States of America
| | - Sanford M. Dawsey
- National Cancer Institute, Department of Cancer Epidemiology and Genetics, Metabolic Epidemiology Branch, Rockville, Maryland, United States of America
| | - Satish Gopal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Kamija S. Phiri
- Kamuzu University of Health Sciences, School of Public Health, Blantyre, Malawi
| | - Christian C. Abnet
- National Cancer Institute, Department of Cancer Epidemiology and Genetics, Metabolic Epidemiology Branch, Rockville, Maryland, United States of America
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9
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Buckle GC, Mrema A, Mwachiro M, Ringo Y, Selekwa M, Mulima G, Some FF, Mmbaga BT, Mody GN, Zhang L, Paciorek A, Akoko L, Ayuo P, Burgert S, Bukusi E, Charles A, Chepkemoi W, Chesumbai G, Kaimila B, Kenseko A, Kibwana KS, Koech D, Macharia C, Moirana EN, Mushi BP, Mremi A, Mwaiselage J, Mwanga A, Ndumbalo J, Nvakunga G, Ngoma M, Oduor M, Oloo M, Opakas J, Parker R, Seno S, Salima A, Servent F, Wandera A, Westmoreland KD, White RE, Williams B, Mmbaga EJ, Van Loon K. Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study. BMC Cancer 2022; 22:82. [PMID: 35045815 PMCID: PMC8772224 DOI: 10.1186/s12885-021-09124-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022] Open
Abstract
Background Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. Methods This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. Discussion This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. Trial registration This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021, NCT05177393. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-09124-5.
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Affiliation(s)
- Geoffrey C Buckle
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 505 Parnassus Ave, M1296, San Francsico, CA, 94143, USA.
| | - Alita Mrema
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | - Yona Ringo
- Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Fatma F Some
- Moi University School of Medicine, Eldoret, Kenya
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Gita N Mody
- University of North Carolina, Chapel Hill, USA
| | - Li Zhang
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 505 Parnassus Ave, M1296, San Francsico, CA, 94143, USA
| | - Alan Paciorek
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 505 Parnassus Ave, M1296, San Francsico, CA, 94143, USA
| | - Larry Akoko
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paul Ayuo
- Moi University School of Medicine, Eldoret, Kenya
| | | | | | | | | | | | | | - Aida Kenseko
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - David Koech
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | | | | | - Alex Mremi
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Ally Mwanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Gissela Nvakunga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | - Mark Oloo
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Jesse Opakas
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Robert Parker
- Tenwek Hospital, Bomet, Kenya.,Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Saruni Seno
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Furaha Servent
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Kate D Westmoreland
- University of North Carolina, Chapel Hill, USA.,UNC-Project Malawi, Lilongwe, Malawi
| | - Russell E White
- Tenwek Hospital, Bomet, Kenya.,Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | | | - Elia J Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Katherine Van Loon
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 505 Parnassus Ave, M1296, San Francsico, CA, 94143, USA
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10
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Mwachiro M, Topazian HM, Kayamba V, Mulima G, Ogutu E, Erkie M, Lenga G, Mutie T, Mukhwana E, Desalegn H, Berhe R, Meshesha BR, Kaimila B, Kelly P, Fleischer D, Dawsey SM, Topazian MD. Gastrointestinal endoscopy capacity in Eastern Africa. Endosc Int Open 2021; 9:E1827-E1836. [PMID: 34790551 PMCID: PMC8589549 DOI: 10.1055/a-1551-3343] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity. Patients and methods In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020. Results Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services. Conclusions Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.
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Affiliation(s)
- Michael Mwachiro
- Department of Endoscopy and Surgery, Tenwek Hospital, Bomet, Kenya
| | - Hillary M. Topazian
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | | | | | - Elly Ogutu
- Department of Clinical Medicine & Therapeutics, University of Nairobi, Kenya
- World Gastroenterology Organization Training Centre, Nairobi, Kenya
| | - Mengistu Erkie
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Addis Ababa University, College of Health Sciences, Ethiopia
| | - Gome Lenga
- Department of Medical Services, Kenya Ports Authority
| | - Thomas Mutie
- World Gastroenterology Organization Training Centre, Nairobi, Kenya
- Department of Gastroenterology, Nairobi Hospital
| | - Eva Mukhwana
- World Gastroenterology Organization Training Centre, Nairobi, Kenya
| | - Hailemichael Desalegn
- Division of Gastroenterology and Hepatology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Rezene Berhe
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Addis Ababa University, College of Health Sciences, Ethiopia
| | - Berhane Redae Meshesha
- Department of Surgery, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Paul Kelly
- University of Zambia School of Medicine, Lusaka, Zambia
| | - David Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Sanford M. Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States
| | - Mark D. Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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11
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An SJ, Purcell LN, Mulima G, Charles AG. Characteristics and outcomes following motorized and non-motorized vehicular trauma in a resource-limited setting. Injury 2021; 52:2645-2650. [PMID: 33879340 PMCID: PMC8429052 DOI: 10.1016/j.injury.2021.04.035] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite the ubiquity of motorized vehicular transport, non-motorized transportation continues to be common in sub-Saharan Africa. METHODS We performed a retrospective analysis of trauma patients presenting to Kamuzu Central Hospital in Malawi from February 2008 to May 2018. Demographic and clinical variables including injury characteristics and outcomes were collected. We performed bivariate and multivariate logistic regression to determine predictors of mortality following non-motorized vehicular trauma. RESULTS This study included 36,412 patients involved in vehicular road injuries. Patients in the non-motorized group had a preponderance of men (84% versus 73%, p<0.01). The proportion of patients with Glasgow Coma Scale > 8 was slightly higher in the non-motorized group (99% versus 98%, p<0.01), though injury severity did not differ significantly between the two groups. A higher proportion in the motorized group had the most severe injury of contusions and abrasions (56% versus 50%, p<0.01). In contrast, the non-motorized group had a higher proportion of orthopedic injuries (24% versus 16%, p<0.01). The crude mortality rate was 4.51% and 2.15% in the motorized and non-motorized groups, respectively. After controlling for demographic factors and injury severity, the incidence rate ratio of mortality did not differ significantly between motorized and non-motorized trauma groups (IRR 0.91, p=0.35). CONCLUSIONS Non-motorized vehicular trauma remains a significant proportion of morbidity and mortality resulting from road traffic injuries. The injury severity and incidence rate ratio of mortality did not differ between motorized and non-motorized trauma groups. Health care providers should not underestimate the severity of injuries from non-motorized trauma.
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Affiliation(s)
- Selena J. An
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura N. Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Anthony G. Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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12
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Sundet M, Mulima G, Kajombo C, Gjerde H, Christophersen AS, Young S. Adult pedestrian and cyclist injuries in Lilongwe, Malawi: a cross-sectional study. Malawi Med J 2021; 32:197-204. [PMID: 34457204 PMCID: PMC8364799 DOI: 10.4314/mmj.v32i4.4] [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] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Pedestrian and cyclist injuries are a major concern globally, but especially in low-income countries. Locally conducted research is needed to measure the size of the problem and advise policy on road safety interventions. We wanted to investigate the precise circumstances of these injuries in Lilongwe, Malawi and to identify risk factors for severe injuries. Methods Cross-sectional study of all adult pedestrian and cyclist injuries presenting to a large central hospital. This was a sub-study of a larger study with all types of road users included. All patients provided detailed information about the incidents leading to injury and were tested for alcohol. Results There were 222 pedestrians, 183 bicycle riders and 42 bicycle passengers among the 1259 adult road traffic injury victims that were treated at Kamuzu Central Hospital during a 90-day period in 2019. Of these injuries, 60.2% occurred while the victim was walking/cycling along the road and 22.3% when the victim was trying to cross the road. The majority of the victims were men (89.1%). Helmet use for bicyclists was almost non-existent. Only 1 patient had used reflective devices when injured in the dark, despite 44.7% of these injuries occurring in reduced light conditions. There was an increased risk for serious and fatal injuries for pedestrians compared with bicyclists, and also compared with all types of road users. Patients injured in rural areas and those hit by lorries were more severely injured. Consuming alcohol before being injured was associated with more severe injuries in bicyclists. Being injured while crossing the road at painted zebra crossings was associated with an increased risk of serious and potentially fatal injuries. Conclusion This study identified important risk factors for severe injuries in pedestrians and cyclists. Implications for preventive measures are presented in a Haddon Matrix.
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Affiliation(s)
- Mads Sundet
- Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Chifundo Kajombo
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Hallvard Gjerde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | | | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,College of Medicine, University of Malawi, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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13
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Mulima G, Purcell LN, Maine R, Bjornstad EC, Charles A. Epidemiology of prehospital trauma deaths in Malawi: A retrospective cohort study. Afr J Emerg Med 2021; 11:258-262. [PMID: 33859929 PMCID: PMC8027520 DOI: 10.1016/j.afjem.2021.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/25/2021] [Accepted: 03/13/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Trauma is among the leading causes of death and disability in both adults and children worldwide. In Malawi, trauma patients are commonly brought in dead (BID). We aimed to describe the prevalence, sociodemographic, and injury-related characteristics of patients BID to Kamuzu Central Hospital (KCH), a referral hospital in Lilongwe, Malawi. Methods We retrospectively reviewed records of all patients BID in the trauma surveillance registry at KCH from February 2008 to September 2019. We excluded patients BID that did not present to the emergency centre, and were instead taken to the mortuary directly. We used descriptive statistics to evaluate the epidemiology of patients BID. Results We reviewed 106,198 trauma records and 1889 (1.8%) were BID patients. Most patients BID were male, in both adult (n = 1337/1528, 88.4%) and children (n = 231/360, 64.9%) cohorts. The mean age was 34.7 (SD 11.9) years in adults and 7.8 (SD 5.4) years in children. Among the adult BID patients, 33.2% were unemployed, 25.6% were construction workers, and 10.1% were small business owners or managers. The common injury mechanisms in adults were road traffic-related injuries (RTIs) (47.1%) and assaults (23.6%). In children, injuries resulted from RTIs (39.7%), with 74.4% of those were pedestrians hit by cars, drowning (22.9%), and burns (12.4%). In both groups, most injuries occurred on roads (60.2%) or at home (22.1%). Reported alcohol use at the time of trauma was present in 6.3%. The police (57.9%) and privately-owned vehicles (26.6%) transported most BID patients to KCH. Conclusion Efforts to reduce prehospital trauma mortality must focus on improving prehospital care, including training the police and community in basic life support and improving resources towards prehospital trauma care. Further efforts to reduce prehospital mortality must aim to decrease injuries on the roads and at home.
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14
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Sundet M, Mulima G, Kajombo C, Gjerde H, Christophersen AS, Madsen JE, Young S. Geographical mapping of road traffic injuries in Lilongwe, Malawi. Injury 2021; 52:806-813. [PMID: 33712299 DOI: 10.1016/j.injury.2021.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/24/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Road traffic injuries are a leading cause of death and disability, especially in low- and middle-income countries. Identifying injury hotspots are valuable for introducing preventive measures. This is usually accomplished by using police data, but these are often unreliable in low-income countries. This study aimed to identify hotspots for injuries by collecting geographical data in the emergency room. METHODS This was a cross-sectional study of adult road traffic injury patients presenting to the Casualty Department in the central hospital in Lilongwe, the capital of Malawi. An electronic tablet with downloaded maps and satellite photos was used to establish the exact location of the injuries. The geographical data were analyzed with geographic information software. RESULTS We included 1244 road traffic injured patients, of which 23.9% were car passengers or drivers, 18.6% were motorcyclists, 17.8% were pedestrians and 18.0% were cyclists or bicycle passengers. Heatmaps of the injuries identified 5 locations where the incidence of injuries was especially high, and 148 patients were injured in these hotspots during the 90 days of inclusion. Four of these hotspots were along the main road through the capital. Age over 55, rural setting, alcohol use before the injury, high speed limit at the site of injury and being a pedestrian or motorcyclist were significantly associated with a higher degree of injury severity. Around half of the patients that were injured in a four-wheeled vehicle did not use a seat belt, and these patients had a much higher risk of getting a more severe injury. CONCLUSION We have identified specific locations with a high incidence of road traffic injuries in Lilongwe, Malawi, with a simple methodology and within a short time frame. The study demonstrates the feasibility of collecting geographical data at admission to hospital.
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Affiliation(s)
- Mads Sundet
- Diakonhjemmet Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Chifundo Kajombo
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Hallvard Gjerde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | | | - Jan Erik Madsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi; College of Medicine, University of Malawi, Lilongwe, Malawi; Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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15
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Gallaher JR, Mulima G, Qureshi J, Shores CG, Charles AG. The role of endoscopy after upper gastrointestinal bleeding in sub-Saharan Africa: A prospective observational cohort study. Malawi Med J 2021; 32:139-145. [PMID: 33488985 PMCID: PMC7812143 DOI: 10.4314/mmj.v32i3.6] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Upper gastrointestinal (UGI) bleed is a common surgical disease in sub-Saharan Africa where there is often a lack of diagnostic and interventional adjuncts such as endoscopy. This study sought to characterize the role of endoscopy in management of acute UGI bleeding. Materials and Methods This is a prospective observational analysis of adults presenting with an UGI bleed to a tertiary center in Lilongwe, Malawi, over two years. Patients were classified as having no endoscopy, diagnostic endoscopy, or endoscopy with variceal banding. Bivariate, survival analysis, and logistic regression analyses were used to compare intervention cohorts. Results 293 patients were included with 49 patients (16.7%) receiving endoscopy with banding, 65 (22.2%) patients receiving diagnostic endoscopy only, and 179 (61.1%) receiving no endoscopy. Upon survival analysis comparing to the no endoscopy group, cox hazard modelling showed an adjusted hazard ratio over 30 days of 0.12 (95% CI 0.02, 0.88, p=0.038) for the endoscopic banding group and a hazard ratio of 0.39 (95% CI 0.13, 1.16, p=0.090) for the diagnostic endoscopy only group. Physical exam findings consistent with cirrhosis and decreasing age were independent predictors of an endoscopic diagnosis of variceal bleeding. Conclusion Esophagogastric varices are a common cause of UGI bleeding in sub-Saharan Africa and can be predicted with age and physical exam findings. Endoscopy with variceal banding has a survival benefit for patients presenting with acute UGI bleed even with relatively low utilization. Appropriately triaging patients with likely variceal bleeding and improving endoscopy capacity would likely have a significant impact on mortality.
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Affiliation(s)
- Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, CB# 7228, Chapel Hill, NC, USA
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Javeria Qureshi
- Department of Surgery, University of North Carolina School of Medicine, CB# 7228, Chapel Hill, NC, USA
| | - Carol G Shores
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Otolaryngology/Head & Neck Surgery University of North Carolina School of Medicine, CB#7070, Chapel Hill, NC, USA
| | - Anthony G Charles
- Department of Surgery, University of North Carolina School of Medicine, CB# 7228, Chapel Hill, NC, USA.,Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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16
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Purcell LN, Mulima G, Reiss R, Gallaher J, Charles A. Epidemiological Comparisons and Risk Factors for Pre-hospital and In-Hospital Mortality Following Traumatic Injury in Malawi. World J Surg 2021; 44:2116-2122. [PMID: 32157403 DOI: 10.1007/s00268-020-05470-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality. METHODS A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD. RESULTS Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52-2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34-1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11-1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14-1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD. CONCLUSIONS Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gift Mulima
- Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC, USA
| | - Rachel Reiss
- Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC, USA. .,Kamuzu Central Hospital, Lilongwe, Malawi.
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17
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Mushi BP, Mwachiro MM, Buckle G, Kaimila BN, Mulima G, Kayamba V, Kelly P, Akoko L, Mmbaga EJ, Selekwa M, Ringo Y, Pritchett N, White RE, Topazian MD, Fleischer DE, Dawsey SM, Van Loon K. Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy. JCO Glob Oncol 2021; 7:118-126. [PMID: 33449802 PMCID: PMC8081508 DOI: 10.1200/go.20.00318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 06/25/2020] [Revised: 08/29/2020] [Accepted: 10/29/2020] [Indexed: 01/25/2023] Open
Abstract
PURPOSE The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. METHODS In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. RESULTS Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. CONCLUSION The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.
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Affiliation(s)
- Beatrice P. Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Geoffrey Buckle
- Global Cancer Program, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, CA
| | | | | | | | - Paul Kelly
- University of Zambia School of Medicine, Lusaka, Zambia
| | - Larry Akoko
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Elia J. Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Yona Ringo
- Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Natalie Pritchett
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | | | | | - Sanford M. Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Katherine Van Loon
- Global Cancer Program, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, CA
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Sundet M, Kajombo C, Mulima G, Bogstrand ST, Varela C, Young S, Christophersen AS, Gjerde H. Prevalence of alcohol use among road traffic crash victims presenting to a Malawian Central Hospital: A cross-sectional study. Traffic Inj Prev 2020; 21:527-532. [PMID: 33064031 DOI: 10.1080/15389588.2020.1819990] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 04/30/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Alcohol consumption is a well-known risk factor for sustaining road traffic injuries worldwide. Malawi is a low-income country with a large and increasing burden of road traffic injuries. It has generally been viewed as a country with relatively little alcohol consumption. This study investigates the role of alcohol in road traffic injuries in and around the capital Lilongwe. METHODS All patients presenting to the emergency department of Kamuzu Central Hospital after being injured in road traffic crashes were asked to participate in the study. Alcohol testing was done with a breathalyzer or a saliva test. Participants were asked about alcohol use before the injury as well as hazardous drinking using the AUDIT-C questionnaire. RESULTS Of 1347 patients age 18 years or older who were asked to participate, 1259 gave informed consent, and data on alcohol use (alcohol test results and/or self-reported intake) were available for 1251 participants. Of those, 251 (20.1%) tested positive for alcohol, whereas 221 (17.7%) reported alcohol use before the crash; in total 311 (24.9%, 95% CI 22.5-27.3) either tested positive, reported use, or both. Females had a low prevalence of alcohol use (2.5%), while 30.6% of males had consumed alcohol before the injuries. Pedestrians had the highest prevalence at 41.8% (95% CI 35.5-48.4), while car drivers had 23.8% (95% CI 18.2-30.5). Among male pedestrians, 49.5% had used alcohol before the injury. Alcohol-associated injuries had a peak in the evening and at night, especially in the weekends. Of the patients, 63.1% reported that they had not consumed alcohol during the last year, while 21.4% had an AUDIT-C score suggesting hazardous drinking, and 66.2% of those had used alcohol before the injury. CONCLUSIONS A large percentage of road traffic injured patients had been drinking alcohol before their injury, especially male pedestrians. A large proportion of the patients were abstaining from alcohol, but those not abstaining had a high prevalence both of alcohol use when injured and hazardous drinking identified by AUDIT-C. This has important implications for prevention.
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Affiliation(s)
- Mads Sundet
- Department of Orthopedics, Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Chifundo Kajombo
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- College of Medicine, University of Malawi, Lilongwe, Malawi
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- College of Medicine, University of Malawi, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | | | - Hallvard Gjerde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
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19
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Purcell LN, Mulima G, Nip E, Naomi Yohann A, Gallaher JR, Charles AG. Police Transportation of the Critically Injured to a Trauma Center and Risk of Mortality in a Resource-Poor Setting. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.246] [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: 10/23/2022]
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20
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An SJ, Purcell LN, Mulima G, Charles AG. Characteristics and Outcomes after Motorized and Non-Motorized Vehicular Trauma in a Resource-Poor Setting. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.232] [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: 10/23/2022]
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21
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Kincaid JA, Mulima G, Chilingulo I, Charles AG, Maine RG. Early Comparison of Trauma Patients at a District Hospital and its Referral Hospital in Malawi. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.287] [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: 10/25/2022]
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22
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Abstract
BACKGROUND The contribution of interpersonal violence (IPV) to trauma burden varies greatly by region. The high rates of IPV in sub-Saharan Africa are thought to relate in part to the high rates of collective violence. Malawi, a country with no history of internal collective violence, provides an excellent setting to evaluate whether collective violence drives the high rates of IPV in this region. METHODS This is a retrospective review of a prospective trauma registry from 2009 through 2016 at Kamuzu Central Hospital in Lilongwe, Malawi. Adult (>16 years) victims of IPV were compared with non-intentional trauma victims. Log binomial regression determined factors associated with increased risk of mortality for victims of IPV. RESULTS Of 72 488 trauma patients, 25 008 (34.5%) suffered IPV. Victims of IPV were more often male (80.2% vs. 74.8%; p<0.001), younger (median age: 28 years (IQR: 23-34) vs. 30 years (IQR: 24-39); p<0.001), and were more often admitted at night (47.4% vs. 31.9%; p<0.001). Of the IPV victims, 16.5% admitted alcohol use, compared with only 4.4% in other trauma victims (p<0.001). In regression modeling, compared with extremity injuries, head injuries (3.14, 2.24-4.39; p<0.001) and torso injuries (4.32, 2.98-6.27; p<0.001) had increased risk of mortality. Compared with other or unknown mechanisms, penetrating injuries also had increased risk of mortality (1.46, 95% CI 1.17 to 1.81, p=0.001). Alcohol use was associated with a lower risk of mortality (0.54, 95% CI 0.39 to 0.75; p<0.001). DISCUSSION Even in a sub-Saharan country that never experienced internal collective violence, IPV injury rates are high. Public health efforts to measure and address alcohol use, and studies to determine the role of "mob justice," poverty, and intimate partner violence in IPV, in Malawi are needed. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rebecca G Maine
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brittney Williams
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer A Kincaid
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Trista D Reid
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony G Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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23
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Kincaid JA, Mulima G, Charles AG, Maine R. Mortality after Mass-Casualty Incidents in Sub-Saharan Africa. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.415] [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: 11/26/2022]
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24
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Van Loon K, Mwachiro MM, Abnet CC, Akoko L, Assefa M, Burgert SL, Chasimpha S, Dzamalala C, Fleischer DE, Gopal S, Iyer PG, Kaimila B, Kayamba V, Kelly P, Leon ME, Mathew CG, Menya D, Middleton D, Mlombe Y, Mmbaga BT, Mmbaga E, Mulima G, Murphy G, Mushi B, Mwanga A, Mwasamwaja A, Parker MI, Pritchett N, Schüz J, Topazian MD, White RE, McCormack V, Dawsey SM. The African Esophageal Cancer Consortium: A Call to Action. J Glob Oncol 2018; 4:1-9. [PMID: 30241229 PMCID: PMC6223465 DOI: 10.1200/jgo.17.00163] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 12/11/2022] Open
Abstract
Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death; however, worldwide incidence and mortality rates do not reflect the geographic variations in the occurrence of this disease. In recent years, increased attention has been focused on the high incidence of esophageal squamous cell carcinoma (ESCC) throughout the eastern corridor of Africa, extending from Ethiopia to South Africa. Nascent investigations are underway at a number of sites throughout the region in an effort to improve our understanding of the etiology behind the high incidence of ESCC in this region. In 2017, these sites established the African Esophageal Cancer Consortium. Here, we summarize the priorities of this newly established consortium: to implement coordinated multisite investigations into etiology and identify targets for primary prevention; to address the impact of the clinical burden of ESCC via capacity building and shared resources in treatment and palliative care; and to heighten awareness of ESCC among physicians, at-risk populations, policy makers, and funding agencies.
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Affiliation(s)
- Katherine Van Loon
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Michael M. Mwachiro
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Christian C. Abnet
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Larry Akoko
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Mathewos Assefa
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Stephen L. Burgert
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Steady Chasimpha
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Charles Dzamalala
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - David E. Fleischer
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Satish Gopal
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Prasad G. Iyer
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Bongani Kaimila
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Violet Kayamba
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Paul Kelly
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Maria E. Leon
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Christopher G. Mathew
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Diana Menya
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Daniel Middleton
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Yohannie Mlombe
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Blandina T. Mmbaga
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Elia Mmbaga
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Gift Mulima
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Gwen Murphy
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Beatrice Mushi
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Ally Mwanga
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Amos Mwasamwaja
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - M. Iqbal Parker
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Natalie Pritchett
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Joachim Schüz
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Mark D. Topazian
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Russell E. White
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Valerie McCormack
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
| | - Sanford M. Dawsey
- Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Michael M. Mwachiro, Stephen L. Burgert, and Russell E. White, Tenwek Hospital, Bomet; Diana Menya, Moi University, Eldoret, Kenya; Christian C. Abnet, Gwen Murphy, Natalie Pritchett, and Sanford M. Dawsey, National Cancer Institute, Bethesda, MD; Larry Akoko, Elia Mmbaga, Beatrice Mushi, and Ally Mwanga, Muhimbili University of Health and Allied Sciences, Dar es Salaam; Blandina T. Mmbaga and Amos Mwasamwaja, Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Mathewos Assefa, Addis Ababa University, Addis Ababa, Ethiopia; Steady Chasimpha and Charles Dzamalala, Queen Elizabeth Central Hospital; Charles Dzamalala, Satish Gopal, Bongani Kaimila, and Yohannie Mlombe, University of Malawi College of Medicine, Blantyre; Gift Mulima, Kamuzu Central Hospital, Lilongwe, Malawi; David E. Fleischer, Mayo Clinic, Phoenix, AZ; Satish Gopal, University of North Carolina, Chapel Hill, NC; Prasad G. Iyer and Mark D. Topazian, Mayo Clinic, Rochester, MN; Violet Kayamba and Paul Kelly, University of Zambia, Lusaka, Zambia; Paul Kelly, Queen Mary University of London; Christopher G. Mathew, King’s College London, London, United Kingdom; Maria E. Leon, Daniel Middleton, Joachim Schüz, and Valerie McCormack, International Agency for Research on Cancer, Lyon, France; Christopher G. Mathew, University of the Witwatersrand, Johannesburg; and M. Iqbal Parker, University of Cape Town, Cape Town, South Africa
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Gallaher JR, Mulima G, Kopp D, Shores CG, Charles AG. Consequences of centralised blood bank policies in sub-Saharan Africa. Lancet Glob Health 2018; 5:e131-e132. [PMID: 28104174 DOI: 10.1016/s2214-109x(16)30364-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 7728, USA
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Dawn Kopp
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carol G Shores
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 7728, USA; Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Anthony G Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 7728, USA; Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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Liu W, Snell JM, Jeck WR, Hoadley KA, Wilkerson MD, Parker JS, Patel N, Mlombe YB, Mulima G, Liomba NG, Wolf LL, Shores CG, Gopal S, Sharpless NE. Subtyping sub-Saharan esophageal squamous cell carcinoma by comprehensive molecular analysis. JCI Insight 2017; 2:98457. [PMID: 29148985 DOI: 10.1172/jci.insight.98457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Eaton JC, Hanif AB, Mulima G, Kajombo C, Charles A. 198 Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource-Poor Setting. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.198] [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: 11/14/2022] Open
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Murphy G, McCormack V, Abedi-Ardekani B, Arnold M, Camargo MC, Dar NA, Dawsey SM, Etemadi A, Fitzgerald RC, Fleischer DE, Freedman ND, Goldstein AM, Gopal S, Hashemian M, Hu N, Hyland PL, Kaimila B, Kamangar F, Malekzadeh R, Mathew CG, Menya D, Mulima G, Mwachiro MM, Mwasamwaja A, Pritchett N, Qiao YL, Ribeiro-Pinto LF, Ricciardone M, Schüz J, Sitas F, Taylor PR, Van Loon K, Wang SM, Wei WQ, Wild CP, Wu C, Abnet CC, Chanock SJ, Brennan P. International cancer seminars: a focus on esophageal squamous cell carcinoma. Ann Oncol 2017; 28:2086-2093. [PMID: 28911061 PMCID: PMC5834011 DOI: 10.1093/annonc/mdx279] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) have initiated a series of cancer-focused seminars [Scelo G, Hofmann JN, Banks RE et al. International cancer seminars: a focus on kidney cancer. Ann Oncol 2016; 27(8): 1382-1385]. In this, the second seminar, IARC and NCI convened a workshop in order to examine the state of the current science on esophageal squamous cell carcinoma etiology, genetics, early detection, treatment, and palliation, was reviewed to identify the most critical open research questions. The results of these discussions were summarized by formulating a series of 'difficult questions', which should inform and prioritize future research efforts.
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Affiliation(s)
- G. Murphy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | | | | | - M. Arnold
- Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - M. C. Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - N. A. Dar
- Department of Biochemistry, University of Kashmir, Hazratbal, Srinagar, Jammu and Kashmir, India
| | - S. M. Dawsey
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - A. Etemadi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - R. C. Fitzgerald
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - D. E. Fleischer
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - N. D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - A. M. Goldstein
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - S. Gopal
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - M. Hashemian
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - N. Hu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - P. L. Hyland
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - B. Kaimila
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - F. Kamangar
- Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, Maryland, USA
| | - R. Malekzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - C. G. Mathew
- Department of Medical and Molecular Genetics, Kings College London
- Sydney Brenner Institute for Molecular Bioscience, University of Witwatersrand, Johannesburg, South Africa
| | - D. Menya
- School of Public Health, Moi University, Eldoret, Kenya
| | - G. Mulima
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - A. Mwasamwaja
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - N. Pritchett
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - Y.-L. Qiao
- Department of Etiology and Carcinogenesis & Department of Cancer Epidemiology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - L. F. Ribeiro-Pinto
- Molecular Carcinogenesis Program, Institute Nacional de Cancer, Sao Paulo, Brazil
| | - M. Ricciardone
- National Cancer Institute, Center for Global Health, National Institutes of Health, Bethesda, Maryland, USA
| | - J. Schüz
- Section of Environment and Radiation
| | - F. Sitas
- School of Public Health, University of Sydney, New South Wales, Australia
- School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - P. R. Taylor
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - K. Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California, USA
| | - S.-M. Wang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
- Department of Etiology and Carcinogenesis & Department of Cancer Epidemiology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - W.-Q. Wei
- Department of Etiology and Carcinogenesis & Department of Cancer Epidemiology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - C. P. Wild
- Director's office, International Agency for Research on Cancer, Lyon, France
| | - C. Wu
- Department of Etiology and Carcinogenesis & Department of Cancer Epidemiology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - C. C. Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
| | - S. J. Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda Maryland, USA
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Eaton J, Hanif AB, Mulima G, Kajombo C, Charles A. Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource Poor Setting. World Neurosurg 2017; 105:257-264. [PMID: 28583456 DOI: 10.1016/j.wneu.2017.05.153] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 03/21/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The incidence of TBI in low- and middle-income countries (LMICs) is disproportionately high, with an associated increased risk of mortality from TBI relative to high-income countries. Although computed tomography is the diagnostic method of choice, this is often unavailable in LMICs. Exploratory burr holes may provide a suitable choice for diagnosis and treatment of TBI. METHODS We performed a retrospective review of prospectively collected data at KCH, a tertiary care center in Lilongwe, Malawi. All trauma patients presenting between June 2012 and July 2015 with a deteriorating level of consciousness and localizing signs and who underwent exploratory burr holes were included. Additionally, we included all patients admitted with TBI, requiring higher-level care during 2011. No patients underwent exploratory burr hole during this time. We performed logistic regression to identify predictors of mortality in the total population of TBI patients. RESULTS Among the 241 patients who presented to KCH with TBI requiring higher-level care, the total mortality was 16.4%. More than half (163, or 68%) underwent exploratory burr hole with a mortality of 6.8%. Mortality in patients who did not undergo exploratory burr hole was 43.9%. Upon adjusted logistic regression, not undergoing exploratory burr hole significantly increased the odds of mortality (odds ratio = 12.0, P = 0.000, 95% confidence interval = 4.48-31.9). CONCLUSION Exploratory burr holes remain an important diagnostic and therapeutic procedure for TBI in LMICs. Exploratory burr hole technique should be integrated into general surgery education to attenuate TBI-related mortality.
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Affiliation(s)
| | - Asma Bilal Hanif
- Department of Surgery, Kamuzu Central Hospitals, Lilongwe, Malawi
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospitals, Lilongwe, Malawi
| | - Chifundo Kajombo
- Department of Surgery, Kamuzu Central Hospitals, Lilongwe, Malawi
| | - Anthony Charles
- UNC-Project Malawi, Lilongwe, Malawi; Department of Surgery, Kamuzu Central Hospitals, Lilongwe, Malawi; Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA.
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Mipando M, Mkandawire N, Masiye J, Wroe E, Dullie L, Mataya R, Muula A, Mwapatsa V, Dzamalala C, Masamba L, Tomoka T, Moses A, Chinula L, Kaimila B, Mulima G, Nyasosela R, Ngoma J, Chunda L, Namarika D, Kamiza S, Nyirenda M, Crampin A, Gordon S, Eckerle M, Ware R, Berman J, van Oesterhout J, Sclafani J, El-Mallawany NK, Wasswa P, Kazembe P, Dadabhai S, Taha T, Kumwenda J, McCollum E, Damania B, Charles A, Fedoriw Y, Dittmer D, Hosseinipour M, Hoffman I, Phiri S, Gopal S. Leveraging HIV Research and Implementation for Cancer and Noncommunicable Diseases in Malawi. J Glob Oncol 2017. [DOI: 10.1200/jgo.2017.009407] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 33 Background: Enabled by collaboration and political stability, Malawi is a global leader for HIV research and implementation. We undertook this work to identify ways to leverage successes in HIV treatment and research for cancer and noncommunicable diseases (NCDs). Methods: Over more than two decades, investment from the National Institutes of Health (NIH) and other funders has allowed Malawi participation in international HIV networks. As these sought to address HIV-positive cancer, investment occurred to increase pathology, improve cancer registration, scale up cervical cancer screening, and improve nursing and pharmacy skills for chemotherapy administration. This allowed Malawi to participate in multinational clinical trials for HIV-positive Kaposi sarcoma treatment and cervical cancer prevention. Building on this, Malawi was one of six countries in 2014 to receive an NIH U54 consortium award for HIV-positive malignancies and was one of six countries added to the National Cancer Institute (NCI) AIDS Malignancy Consortium. In 2016, expanding beyond HIV-positive cancer, Malawi was one of three countries invited to join a new NCI–International Agency for Research on Cancer esophageal cancer consortium, one of five recipients of a new NCI Burkitt lymphoma award, and one of six recipients of a new NCI P20 grant for a regional center of research excellence for NCDs. Malawi is also one of 11 countries to convene a Lancet noncommunicable diseases and injury poverty commission for NCDs and injury. Finally, partners have improved surveillance and treatment for hypertension, diabetes, injury, and sickle cell anemia, in part, through a national Knowledge Translation Platform for HIV-NCD integration. With this support and funding, career development opportunities are embedded for Malawian NCD researchers. Results: Building on successes in HIV treatment and research, Malawi has become a global leader for cancer and NCD research and implementation. Conclusion: Continue developing a multilateral national platform for NCD research and implementation that is globally impactful and can lead to measurable outputs for individual cancer and NCD focus areas. Funding: National Institutes of Health. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the authors.
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Affiliation(s)
- Mwapatsa Mipando
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Nyengo Mkandawire
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Jones Masiye
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Emily Wroe
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Luckson Dullie
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Ron Mataya
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Adamson Muula
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Victor Mwapatsa
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Charles Dzamalala
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Leo Masamba
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Tamiwe Tomoka
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Agnes Moses
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Lameck Chinula
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Bongani Kaimila
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Gift Mulima
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Richard Nyasosela
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Jonathan Ngoma
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Lilian Chunda
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Dan Namarika
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Steve Kamiza
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Moffat Nyirenda
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Amelia Crampin
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Stephen Gordon
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Michelle Eckerle
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Russell Ware
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Josh Berman
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Joep van Oesterhout
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Joe Sclafani
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Nader Kim El-Mallawany
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Peter Wasswa
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Peter Kazembe
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Sufia Dadabhai
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Taha Taha
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Johnstone Kumwenda
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Eric McCollum
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Blossom Damania
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Anthony Charles
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Yuri Fedoriw
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Dirk Dittmer
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Mina Hosseinipour
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Irving Hoffman
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Sam Phiri
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
| | - Satish Gopal
- Mwapatsa Mipando, Nyengo Mkandawire, Ron Mataya, Adamson Muula, Victor Mwapatsa, Charles Dzamalala, and Steve Kamiza, University of Malawi College of Medicine; Stephen Gordon, Malawi-Liverpool Wellcome Trust, Blantyre; Jones Masiye, Leo Masamba, Gift Mulima, Richard Nyasosela, Jonathan Ngoma, and Lilian Chunda, Malawi Ministry of Health; Dan Namarika, Partners in Hope, Lilongwe; Josh Berman and Joep van Oesterhout, Dignitas International, Zomba, Malawi; Emily Wroe and Luckson Dullie, Partners in Health,
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Murphy G, McCormack V, Menya D, Mmbaga B, Van Loon K, Mmbaga E, Gopal S, Kaimila B, Mulima G, Pritchett N, Mwachiro M, White R, Abnet C, Schuz J, Dawsey S. Development of an African Esophageal Cancer Consortium. J Glob Oncol 2017. [DOI: 10.1200/jgo.2017.009712] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 44 Background: Esophageal cancer is the sixth leading cause of cancer death worldwide. It kills 400,000 people every year, most of whom live in two distinct geographic bands across central Asia and along the eastern Africa corridor that extends from Ethiopia to South Africa. In these high-risk areas, nearly all cases are esophageal squamous cell carcinoma (ESCC). Our group and others have performed many etiologic, genetic, and early detection and treatment studies of ESCC in central Asia, but this disease remains essentially unstudied in eastern Africa. Over the past few years, several groups have begun quality studies of ESCC in Africa, including case-control studies in Dar es Salaam, Tanzania (University of California, San Francisco, and Muhimbili University of Health and Allied Sciences); Eldoret, Kenya (International Agency for Research on Cancer and Moi University); Moshi, Tanzania (International Agency for Research on Cancer and Kilimanjaro Clinical Research Institute); Bomet, Kenya (National Cancer Institute and Tenwek Hospital); and Lilongwe, Malawi (National Cancer Institute and the UNC-Malawi Project). In November 2015, these groups met and decided to create the African Esophageal Cancer Consortium. The goals of the consortium are to raise awareness of the importance of ESCC in Africa, to coordinate etiologic and molecular studies of ESCC in high-risk populations, and to facilitate provision of therapeutic training and equipment aimed to improve survival and quality of life. Methods: The first coordinated activity was to standardize questionnaires so that data can later be compared and combined. The consortium has embraced mobile health technologies through development of an mHealth app for real-time data capture on a phone or tablet and to collect harmonized data from the outset, increase efficiency, eliminate transcription mistakes, and allow real-time quality control and supervision of field activities from any location. Results: The consortium held its second annual meeting in September 2016. At this meeting, the five member sites affirmed their commitment to the consortium and the first study coordinator was named. Conclusion: Case-control studies in Moshi, Bomet, and Lilongwe are using the mobile app. A case-control study in Dar es Salaam is complete, with results pending. Coordinated genome-wide association and genomic studies are planned, with collection of biospecimens from multiple sites. The consortium is actively working with partners in China to provide affordable stents in Africa for palliative ESCC treatment as well as to secure training to safely and effectively place stents. Annual meetings will continue to follow-up on progress and develop new initiatives. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the authors.
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Affiliation(s)
- Gwen Murphy
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Valerie McCormack
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Diana Menya
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Blandina Mmbaga
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Katherine Van Loon
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Elia Mmbaga
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Satish Gopal
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Bongani Kaimila
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Gift Mulima
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Natalie Pritchett
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Michael Mwachiro
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Russell White
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Christian Abnet
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Joachim Schuz
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
| | - Sanford Dawsey
- Gwen Murphy, Natalie Pritchett, Christian Abnet, and Sanford Dawsey, National Cancer Institute, National Institutes of Health, Bethesda, MD; Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Satish Gopal, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Valerie McCormack and Joachim Schuz, International Agency for Research on Cancer, Lyon, France; Diana Menya, College of Health Sciences, Moi University, Eldoret; Michael Mwachiro and Russell White, Tenwek Hospital,
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Liu W, Snell JM, Jeck WR, Hoadley KA, Wilkerson MD, Parker JS, Patel N, Mlombe YB, Mulima G, Liomba NG, Wolf LL, Shores CG, Gopal S, Sharpless NE. Subtyping sub-Saharan esophageal squamous cell carcinoma by comprehensive molecular analysis. JCI Insight 2016; 1:e88755. [PMID: 27734031 DOI: 10.1172/jci.insight.88755] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Esophageal squamous cell carcinoma (ESCC) is endemic in regions of sub-Saharan Africa (SSA), where it is the third most common cancer. Here, we describe whole-exome tumor/normal sequencing and RNA transcriptomic analysis of 59 patients with ESCC in Malawi. We observed similar genetic aberrations as reported in Asian and North American cohorts, including mutations of TP53, CDKN2A, NFE2L2, CHEK2, NOTCH1, FAT1, and FBXW7. Analyses for nonhuman sequences did not reveal evidence for infection with HPV or other occult pathogens. Mutational signature analysis revealed common signatures associated with aging, cytidine deaminase activity (APOBEC), and a third signature of unknown origin, but signatures of inhaled tobacco use, aflatoxin and mismatch repair were notably absent. Based on RNA expression analysis, ESCC could be divided into 3 distinct subtypes, which were distinguished by their expression of cell cycle and neural transcripts. This study demonstrates discrete subtypes of ESCC in SSA, and suggests that the endemic nature of this disease reflects exposure to a carcinogen other than tobacco and oncogenic viruses.
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Affiliation(s)
- Wenjin Liu
- Department of Genetics.,Department of Medicine.,The Lineberger Comprehensive Cancer Center
| | - Jeff M Snell
- The Lineberger Comprehensive Cancer Center.,Program in Bioinformatics and Computational Biology.,Program in Molecular and Cellular Biophysics
| | - William R Jeck
- Department of Genetics.,The Lineberger Comprehensive Cancer Center
| | | | | | - Joel S Parker
- Department of Genetics.,The Lineberger Comprehensive Cancer Center
| | - Nirali Patel
- The Lineberger Comprehensive Cancer Center.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yohannie B Mlombe
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Lindsey L Wolf
- UNC Project-Malawi, Lilongwe, Malawi.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol G Shores
- The Lineberger Comprehensive Cancer Center.,Department of Otolaryngology/Head and Neck Surgery
| | - Satish Gopal
- Department of Medicine.,The Lineberger Comprehensive Cancer Center.,Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.,UNC Project-Malawi, Lilongwe, Malawi.,Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Norman E Sharpless
- Department of Genetics.,Department of Medicine.,The Lineberger Comprehensive Cancer Center
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Samuel JC, Tyson AF, Mabedi C, Mulima G, Cairns BA, Varela C, Charles AG. Development of a ratio of emergent to total hernia repairs as a surgical capacity metric. Int J Surg 2014; 12:906-11. [PMID: 25084098 DOI: 10.1016/j.ijsu.2014.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 08/08/2013] [Revised: 06/05/2014] [Accepted: 07/21/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Non-communicable diseases including surgical conditions are gaining attention in developing countries. Despite this there are few metrics for surgical capacity. We hypothesized that (a) the ratio of emergent to total hernia repairs (E/TH) would correlate with per capita health care expenditures for any given country, and (b) the E/TH is easy to obtain in resource-poor settings. METHODS We performed a systematic review to identify the E/TH for as many countries as possible (Prospero registry CRD42013004645). We screened 1285 English language publications since 1990; 23 met inclusion criteria. Primary data was also collected from Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. A total of 13 countries were represented. Regression analysis was used to determine the correlation between per capita health care spending and the E/TH. RESULTS There is a strong correlation between the log values of the ratio emergent to total groin hernias and the per capita health care spending that is robust across country income levels (R(2) = 0.823). Primary data from KCH was easily obtained and demonstrated a similar correlation. CONCLUSIONS The ratio of emergent to total groin hernias is a potential measure of surgical capacity using data that is easily attainable. Further studies should validate this metric against other accepted health care capacity indicators. Systematic review registered with Prospero (CRD42013004645).
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Affiliation(s)
- Jonathan C Samuel
- NC Jaycee Burn Center, Department of Surgery, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27759, USA.
| | - Anna F Tyson
- Department of Surgery, University of North Carolina, 4001 Burnett Womack Bldg CB 7050, Chapel Hill, NC 27599, USA
| | - Charles Mabedi
- Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Bruce A Cairns
- NC Jaycee Burn Center, Department of Surgery, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27759, USA
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Anthony G Charles
- Department of Surgery, University of North Carolina, 4001 Burnett Womack Bldg CB 7050, Chapel Hill, NC 27599, USA
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Qureshi JS, Samuel JC, Mulima G, Kakoulides S, Cairns B, Charles AG. Validating a verbal autopsy tool to assess pre-hospital trauma mortality burden in a resource-poor setting. Trop Med Int Health 2014; 19:407-12. [PMID: 24617322 DOI: 10.1111/tmi.12268] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To present the validation of a verbal autopsy (VA) tool using inpatient deaths in order to ultimately assess the burden of adult pre-hospital trauma mortality in Lilongwe, Malawi. METHODS A WHO VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe to family members of inpatient deceased. Two physicians assigned cause of death as 'trauma' or 'non-trauma' as well as a standard VA cause of death based on the VA tool. These assignments were compared to the 'gold standard' of physician review of hospital records using a kappa statistic. RESULTS The VA method had near-perfect agreement with the hospital record in determining 'trauma' vs. 'non-trauma'. There was moderate agreement when comparing types of death, for example cardiovascular vs. infectious disease, and limited agreement when comparing specific causes of death. CONCLUSION This VA tool can accurately ascertain trauma-related mortality with almost perfect agreement. The next step is to assess pre-hospital trauma mortality burden using the VA tool to determine whether hospital records underestimate the burden of trauma in the community.
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Affiliation(s)
- Javeria S Qureshi
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Samuel JC, Qureshi JS, Mulima G, Shores CG, Cairns BA, Charles AG. An Observational Study of the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi. World J Emerg Surg 2011; 6:37. [PMID: 22067899 PMCID: PMC3223493 DOI: 10.1186/1749-7922-6-37] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 11/08/2011] [Indexed: 11/12/2022] Open
Abstract
Introduction Peritonitis is a life-threatening condition with a multitude of etiologies that can vary with geographic location. The aims of this study were to elucidate the etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi. Methods All patients admitted to Kamuzu Central Hospital (KCH) who underwent an operation for treatment of peritonitis during the calendar year 2008 were eligible. Peritonitis was defined as abdominal rigidity, rebound tenderness, and/or guarding in one or more abdominal quadrants. Subjects were identified from a review of the medical records for all patients admitted to the adult general surgical ward and the operative log book. Those who met the definition of peritonitis and underwent celiotomy were included. Results 190 subjects were identified. The most common etiologies were appendicitis (22%), intestinal volvulus (17%), perforated peptic ulcer (11%) and small bowel perforation (11%). The overall mortality rate associated with peritonitis was 15%, with the highest mortality rates observed in solid organ rupture (35%), perforated peptic ulcer (33%), primary/idiopathic peritonitis (27%), tubo-ovarian abscess (20%) and small bowel perforation (15%). Factors associated with death included abdominal rigidity, generalized (versus localized) peritonitis, hypotension, tachycardia and anemia (p < 0.05). Age, gender, symptoms (obstipation, vomiting) and symptom duration, tachypnea, abnormal temperature, leukocytosis, hemoconcentration, thrombocytopenia and thrombocytosis were not associated with mortality (p = NS). Conclusions There are several signs and laboratory findings predictive of poor outcome in Malawian patients with peritonitis. Tachycardia, hypotension, anemia, abdominal rigidity and generalized peritonitis are the most predictive of death (P < 0.05 for each). Similar to studies from other African countries, in our population the most common cause of peritonitis was appendicitis, and the overall mortality rate among all patients with peritonitis was 15%. Identified geographical differences included intestinal volvulus, rare in the US but the 2nd most common cause of peritonitis in Malawi and gallbladder disease, common in Ethiopia but not observed in Malawi. Future research should investigate whether correction of factors associated with mortality might improve outcomes.
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Affiliation(s)
- Jonathan C Samuel
- Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi.
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