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1. Creation of an enhanced recovery after surgery protocol for children with Wilms tumours in low- and middle-income countries

Author

Mercedes Pilkington, Mary E. Brindle, and Godfrey Sama Philipo

Subjects
Enhanced recovery after surgery, ERAS, Pediatric, Oncology, LMIC, Global surgery, Pediatrics, RJ1-570, Surgery, RD1-811
Abstract

Introduction: Enhanced Recovery After Surgery guidelines have been developed and shown to improve outcomes for many surgical procedures. Most existing guidelines have been created for patients in high-resource settings. There is a dearth of guidelines for pediatric populations particularly in low- and middle-income countries (LMIC). All children with Wilms tumours require resection for cure and therefore a perioperative care pathway can streamline care for all curative-intent nephrectomies. Methods: A two-round Delphi consensus of clinicians in LMICs was utilized to determine the scope and content of recommendations for an enhanced recovery protocol for children with Wilms tumours undergoing nephrectomy in LMICs. Consensus was predefined a priori as ≥70% of panelists indicating a topic or recommendation should be included. Results: Twenty-six topics met consensus for inclusion and were consolidated into twenty recommendations for implementation in the preoperative, intraoperative, and postoperative setting. Predominant themes included perioperative nutrition, surgical safety, anesthetic concerns, and interdisciplinary oncology care. Ten participants completed round one and six completed round two. All recommendations met consensus for inclusion after two rounds. Conclusions: A consensus-derived perioperative care pathway for children with Wilms tumours in low-resource settings is presented. Recommendations share many priorities with high-resource pathways, but also contain unique considerations for a low-resource setting.

Published
2023
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2. Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa

Author

Rebecca J. DeBoer, Jerry Ndumbalo, Stephen Meena, Mamsau T. Ngoma, Nanzoke Mvungi, Sadiq Siu, Msiba Selekwa, Sarah K. Nyagabona, Rohan Luhar, Geoffrey Buckle, Tracy Kuo Lin, Lindsay Breithaupt, Stephanie Kennell-Heiling, Beatrice Mushi, Godfrey Sama Philipo, Elia J. Mmbaga, Julius Mwaiselage, and Katherine Van Loon

Subjects
Guideline implementation, Implementation strategy, Cancer guidelines, Behavior change, Intervention mapping, Medicine (General), R5-920
Abstract

Abstract Background Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. Methods In preparation for the launch of Tanzania’s first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. Discussion We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of “proven” guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.

Published
2020
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3. Delayed diagnostic evaluation of symptomatic breast cancer in sub-Saharan Africa: A qualitative study of Tanzanian women

Author

Lulu Lunogelo Sakafu, Godfrey Sama Philipo, Christina V. Malichewe, Lulu S. Fundikira, Flora A. Lwakatare, Katherine Van Loon, Beatrice P. Mushi, Rebecca J. DeBoer, Stella A. Bialous, and Amie Y. Lee

Subjects
Medicine, Science
Abstract

Background Women with breast cancer in sub-Saharan Africa are commonly diagnosed at advanced stages. In Tanzania, more than 80% of women are diagnosed with stage III or IV disease, and mortality rates are high. This study explored factors contributing to delayed diagnostic evaluation among women with breast cancer in Tanzania. Methods A qualitative study was performed at Muhimbili National Hospital in Dar es Salaam, Tanzania. Twelve women with symptomatic pathologically proven breast cancer were recruited. In-depth, semi-structured interviews were conducted in Swahili. Interviews explored the women’s journey from symptom recognition to diagnosis, including the influence of breast cancer knowledge and pre-conceptions, health seeking behaviors, psychosocial factors, preference for alternative treatments, and the contribution of culture and norms. Audio-recorded interviews were transcribed and translated into English. Thematic analysis was facilitated by a cloud-based qualitative analysis software. Results All women reported that their first breast symptom was a self-identified lump or swelling. Major themes for factors contributing to delayed diagnostic presentation of breast cancer included lack of basic knowledge and awareness of breast cancer and misconceptions about the disease. Participants faced barriers with their local primary healthcare providers, including symptom mismanagement and delayed referrals for diagnostic evaluation. Other barriers included financial hardships, fear and stigma of cancer, and use of traditional medicine. The advice and influence of family members and friends played key roles in healthcare-seeking behaviors, serving as both facilitators and barriers. Conclusion Lack of basic knowledge and awareness of breast cancer, stigma, financial barriers, and local healthcare system barriers were common factors contributing to delayed diagnostic presentation of breast cancer. The influence of friends and family also played key roles as both facilitators and barriers. This information will inform the development of educational intervention strategies to address these barriers and improve earlier diagnosis of symptomatic breast cancer in Tanzania.

Published
2022

4. Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania

Author

Shobhana Nagraj, Kokila Lakhoo, Godfrey Sama Philipo, and Zaitun M Bokhary

Subjects
Medicine (General), R5-920, Infectious and parasitic diseases, RC109-216
Abstract

Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children’s surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children’s surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children’s surgery in LMICs.

Published
2020
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5. Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania

Author

Dianna L. Ng, Edda Vuhahula, Li Zhang, Emily G. Waterhouse, Kristie L. White, Beatrice Paul Mushi, Msiba Selekwa Nyeriga, Godfrey Sama Philipo, Elia J. Mmbaga, Sujay Sheth, Katherine Van Loon, Amie Y. Lee, and Ronald Balassanian

Subjects
Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract

Background: Fine-needle aspiration biopsy (FNAB) is a minimally invasive, cost-effective diagnostic tool that can be used in low-resource settings. However, adequacy and accuracy of FNAB is highly dependent on the skills of the operator and requires specialized training. Poor technique can preclude definitive diagnoses because of insufficient quality or quantity of FNAB samples. We evaluated the efficacy of an intensive training experience in Tanzania on improving ultrasound-guided FNAB techniques. Methods: A 2-day workshop offered didactic lectures, demonstrations, and hands-on practicum on fundamentals of ultrasound imaging and FNAB technique. A prospective interventional study design was used with pre- and postintervention surveys and assessments to measure the effect of the workshop on specific skills related to slide smearing and ultrasound-guidance among participants. Results: Twenty-six pathologists and radiologists, including trainees in each specialty, participated in the workshop. Pre- and postworkshop assessments demonstrated that most participants improved significantly in nearly all technical skills for slide smearing and ultrasound-guided FNAB. After the workshop, most participants demonstrated substantial improvements in ability to prepare the ultrasound equipment, measure the lesion in three dimensions by ultrasound, target lesions in one pass using both parallel and perpendicular approaches, and prepare high-quality aspirate smears. Conclusion: An in-country 2-day workshop in Tanzania was efficacious in transferring basic skills in FNAB smear preparation and ultrasound-guided FNAB, resulting in skills enhancement among participating pathologists and radiologists. Although mastery of skills was not the goal of this short workshop, participants demonstrated proficiency in most technical elements after workshop completion, and the workshop generated interest among select participants to pursue additional intensive training in cytopathology.

Published
2018
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6. A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

Author

Godfrey Sama Philipo, Zaitun Mohamed Bokhary, Neema Lala Bayyo, Soham Bandyopadhyay, Miriam Gerd Pueschel, Rajabu Athumani Bakari, and Kokila Lakhoo

Subjects
Child, Preschool, Humans, Surgery, Prospective Studies, Child, Referral and Consultation, Tanzania, Hospitals, Specialties, Surgical
Abstract

Background A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children’s journey to surgical care. We aimed to explore children’s journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania. Methods A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann–Whitney, Kruskal–Wallis and Fisher’s exact tests were used for data analysis. Result We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died. Conclusion Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children’s surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.

Published
2022

7. The Use of Simulation for Undergraduate Surgical Education in Sub-Saharan Africa: A Scoping Review

Author

Barnabas Tobi Alayande, Callum Forbes, Ornella Masimbi, Paul KingPriest, Natnael Shimelash, Felix Wina, Matthew T. Hey, Godfrey Sama Philipo, Egide Abahuje, Jamie M. Robertson, Steven Yule, Robert Riviello, and Abebe Bekele

Abstract

Background The implementation of simulation-based learning for surgical training in sub-Saharan Africa can help prepare trainees to address surgical burden. The current status of simulation for surgical skills training in undergraduate medical education in Africa South of the Sahara needs to be better defined. In this scoping review we aimed to identify gaps in the application of simulation to undergraduate surgical education in sub-Saharan Africa. Methods We conducted a scoping literature search using PubMed, Embase, and African Index Medicus in August 2021. Studies reporting data on the use of simulation-based learning for undergraduate or internship surgical training in SSA specific to surgical clerkships, programs or procedures were included in the analysis. There were no language or date restrictions. Results We identified 119 studies and included 19 in the final analysis. Most simulation-based learning for undergraduate surgical training in sub-Saharan Africa began recently (2017–2021), and were reported from Eastern Africa (78%). Half were planned as recurring, sustained simulation programs, and only 25% of programs applied simulation to early undergraduate training. Up to 44% of primary care and 32% of first-level hospital essential surgical procedures, as defined by the Disease Control Priority Program (DCP3), are reported as taught by simulation. Only 15% of programs taught non-technical skills and 14% had engineering collaborations. Conclusions We found a lack of published simulation-based learning for undergraduate medical education in sub-Saharan Africa for 65% of World Health Organization/World Bank Disease Control Priorities 3-defined essential operations. There is need to expand the range and depth of content, and participant spread. Interdisciplinary, trans-sectoral collaboration will enrich simulation program quality, and assist with expansion to other African regions.

Published
2023

8. Delayed diagnostic evaluation of symptomatic breast cancer in sub-Saharan Africa: A qualitative study of Tanzanian women

Author

Lulu Lunogelo Sakafu, Godfrey Sama Philipo, Christina V. Malichewe, Lulu S. Fundikira, Flora A. Lwakatare, Katherine Van Loon, Beatrice P. Mushi, Rebecca J. DeBoer, Stella A. Bialous, Amie Y. Lee, and Mwaka, Amos Deogratius

Subjects
Multidisciplinary, General Science & Technology, Prevention, Social Stigma, Breast Neoplasms, Patient Acceptance of Health Care, Tanzania, Good Health and Well Being, Clinical Research, Behavioral and Social Science, Breast Cancer, Humans, Female, Qualitative Research, Cancer
Abstract

Background Women with breast cancer in sub-Saharan Africa are commonly diagnosed at advanced stages. In Tanzania, more than 80% of women are diagnosed with stage III or IV disease, and mortality rates are high. This study explored factors contributing to delayed diagnostic evaluation among women with breast cancer in Tanzania. Methods A qualitative study was performed at Muhimbili National Hospital in Dar es Salaam, Tanzania. Twelve women with symptomatic pathologically proven breast cancer were recruited. In-depth, semi-structured interviews were conducted in Swahili. Interviews explored the women’s journey from symptom recognition to diagnosis, including the influence of breast cancer knowledge and pre-conceptions, health seeking behaviors, psychosocial factors, preference for alternative treatments, and the contribution of culture and norms. Audio-recorded interviews were transcribed and translated into English. Thematic analysis was facilitated by a cloud-based qualitative analysis software. Results All women reported that their first breast symptom was a self-identified lump or swelling. Major themes for factors contributing to delayed diagnostic presentation of breast cancer included lack of basic knowledge and awareness of breast cancer and misconceptions about the disease. Participants faced barriers with their local primary healthcare providers, including symptom mismanagement and delayed referrals for diagnostic evaluation. Other barriers included financial hardships, fear and stigma of cancer, and use of traditional medicine. The advice and influence of family members and friends played key roles in healthcare-seeking behaviors, serving as both facilitators and barriers. Conclusion Lack of basic knowledge and awareness of breast cancer, stigma, financial barriers, and local healthcare system barriers were common factors contributing to delayed diagnostic presentation of breast cancer. The influence of friends and family also played key roles as both facilitators and barriers. This information will inform the development of educational intervention strategies to address these barriers and improve earlier diagnosis of symptomatic breast cancer in Tanzania.

Published
2021

9. Feasibility of Fine-Needle Aspiration Biopsy and Rapid On-Site Evaluation for Immediate Triage in Breast Cancer Screening in Tanzania

Author

Asteria Kimambo, Katherine Van Loon, Godfrey Sama Philipo, Elia John Mmbaga, Edda Vuhahula, and Dianna Ng

Subjects
Adult, Male, Cancer Research, medicine.medical_specialty, Adolescent, Biopsy, Fine-Needle, Early detection, Breast Neoplasms, Site evaluation, Tanzania, 03 medical and health sciences, Breast cancer screening, Young Adult, 0302 clinical medicine, Breast cancer, Biopsy, Breast Cancer, medicine, Humans, 030212 general & internal medicine, Early Detection of Cancer, Aged, medicine.diagnostic_test, biology, business.industry, ORIGINAL REPORTS, Middle Aged, medicine.disease, biology.organism_classification, Triage, Fine-needle aspiration, Oncology, 030220 oncology & carcinogenesis, Feasibility Studies, Female, Radiology, business
Abstract

PURPOSE Clinical breast examination (CBE) is one of the most common methods used for early detection of breast cancer in low- and middle-income countries. CBE alone is limited by lack of specificity and may result in unnecessary diagnostic procedures. We evaluated the feasibility of integrating CBE, fine-needle aspiration biopsy (FNAB), and rapid on-site evaluation (ROSE) in triaging palpable breast masses for specialized cancer care. MATERIALS AND METHODS An intensive breast cancer screening event was conducted at a national trade fair by a multidisciplinary team of care providers targeting a healthy population in Dar es Salaam, Tanzania. All adults age ≥ 18 years were invited to participate. CBE was performed by oncologists and/or pathologists. FNAB was performed by a pathologist on palpable masses that were then categorized as benign, indeterminate, or suspicious for malignancy or definitively malignant based on ROSE. RESULTS A total of 208 individuals (207 females, one male; median age, 36 years; range, 18-68 years) were screened. Most (90.8%, 189 of 208) had normal findings, whereas 7.2% (15 of 208), 1% (2 of 208), and 1% (2 of 208) had a palpable mass, breast pain, and nipple discharge, respectively. Two participants had lesions too small for palpation-guided biopsy and clinically consistent with fibroadenomas; the participants were counseled, and observation was recommended. FNAB was performed on 13 breast masses, with 9 of 13 (69%) categorized as benign and 4 of 13 (31%) suspicious for malignancy. Final cytopathologic review of referred patients confirmed one case to be breast adenocarcinoma, one was suggestive of fibroadenoma, and two showed inflammations. CONCLUSION Integration of CBE with ROSE and FNAB was feasible in a breast cancer screening program in Tanzania. In settings with constrained resources for cancer care, this may be an effective method for triaging patients with breast masses.

Published
2021

10. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Author

Naomi Jane Wright, Andrew J.M. Leather, Niyi Ade-Ajayi, Nick Sevdalis, Justine Davies, Dan Poenaru, Emmanuel Ameh, Adesoji Ademuyiwa, Kokila Lakhoo, Emily Rose Smith, Abdel Douiri, Maria Elstad, Marcus Sim, Cristiana Riboni, Bruno Martinez-Leo, Melika Akhbari, Stephen Tabiri, Ashrarur Mitul, Dayang Anita Abdul Aziz, Camila Fachin, Alliance Niyukuri, Muhammad Arshad, Fowzia Ibrahim, Natalie Moitt, Mohamed Fahmy Doheim, Hannah Thompson, Harmony Ubhi, Isabelle Williams, Sophia Hashim, Godfrey Sama Philipo, Laura Herrera, Aayenah Yunus, Dominique Vervoort, Samuel Parker, Yousra-Imane Benaskeur, Osaid H. Alser, Nana Adofo-Ansong, Ahmad Alhamid, Hosni khairy Salem, Mahmoud Saleh, Safa Abdal Elrais, Sadi Abukhalaf, Patricia Shinondo, Ibrahim Nour, Emrah Aydin, Agota Vaitkiene, Kelly Naranjo, Andile Maqhawe Dube, Sodumisa Ngwenya, Mina A. Yacoub, Henang Kwasau, Gabriella Hyman, Shrouk Mahmoud Elghazaly, Ibrahim Al-Slaibi, Intisar Hisham, Helena Franco, Hana Arbab, Lubna Samad, Aqil Soomro, Muhammad Amjad Chaudhry, Safina Karim, Muhammad Adnan Khan Khattak, Shireen Anne Nah, Doris Mae Dimatatac, Candy SC Choo, Niveshni Maistry, Ashrarur Rahman Mitul, Samiul Hasan, Sabbir Karim, Hina Yousuf, Taimur Qureshi, Ibrahim Rabi Nour, Raed Nael Al-Taher, Osama Abdul Kareem Sarhan, Luis Garcia-Aparicio, Jordi Prat, Eva Blazquez-Gomez, Xavier Tarrado, Martí Iriondo, Paolo Bragagnini, Segundo Rite, Lars Hagander, Emma Svensson, Sheila Owusu, Alhassan Abdul-Mumin, Dominic Bagbio, Vijay Anand Ismavel, Ann Miriam, Shajin T, Marlene Anaya Dominguez, Monica Ivanov, Andreea Madalina Serban, Miliard Derbew, Mahmoud Elfiky, Maricarmen Olivos Perez, Marcia Abrunhosa Matias, Alexis P Arnaud, Ahmed Negida, Sebastian King, Mohamad Rafi Fazli, Nadia Hamidi, Souhem Touabti, Rossana Francisco Chipalavela, Pablo Lobos, Brendan Jones, Damir Ljuhar, Georg Singer, Annelien Cordonnier, Lorena Jáuregui, Zlatan Zvizdic, Janice Wong, Etienne St-Louis, Qiang Shu, Yang Lui, Catalina Correa, Lucie Pos, Elvyn Alcántara, Erick Féliz, Luis Enrique Zea-Salazar, Liza Ali, Matthieu Peycelon, Nzanzu Kipata Anatole, Cherno S. Jallow, Judith Lindert, Dhruv Ghosh, Cathline Freya Adhiwidjaja, Ahmad Khaleghnejad Tabari, Saran Lotfollahzadeh, Haidar Mohammad Mussein, Fabrizio Vatta, Noemi Pasqua, David Kihiko, Hetal Gohil, Ibrahim R. Nour, Muhammed Elhadi, Suad Ahmed Almada, Gilvydas Verkauskas, Toni Risteski, Alejandro Peñarrieta Daher, Oumaima Outani, James Hamill, Taiwo Lawal, Jack Mulu, Benjamin Yapo, Lily Saldaña, Beda Espineda, Krystian Toczewski, Eugene Tuyishime, Isaac Ndayishimiye, Enaam Raboe, Philip Hammond, Gregor Walker, Ivona Djordjevic, Milind Chitnis, Joonhyuk Son, Sanghoon Lee, Muaad Hussien, Sawazen Malik, Enas Musa Ismail, Ampaipan Boonthai, Nesrine Ben Hadj Dahman, Nigel Hall, Fabiola Ruth Castedo Camacho, Helena Sobrero, Marilyn Butler, Aliev Makhmud, Nathan Novotny, Ahmad G. Hammouri, Maisara Al-Rayyes, Bruce Bvulani, Qais Muraveji, Muhammad Yousuf Murzaie, Ajmal Sherzad, Sayed Aman Haidari, Abdul Baqi Monawar, Dr. Ahmad Zia Samadi, Jesh Thiessen, Ntakarutimana Venant, Sonia Inamuco Hospital, Niyonkuru Jérémie, Jean Claude Mbonicura, Butoyi Jean Marie Vianney, Amezene Tadesse, Samuel Negash, Charles A. Roberts, John N. Jabang, Abdoulie Bah, Kajali Camamra, Armandou Correa, Babucarr Sowe, A. Gai, Musa Jaiteh, Kwizera Jean Raymond, Jean Paul Mvukiyehe, Innocent Itangishaka, Emmanuel Kayibanda, Emery Manirambona, Joseph Lule, Ainhoa Costas-Chavarri, Ian Shyaka Gashugi, Albert Ndata, Georges Gasana, Yves Castar Nezerwa, Turatsinze Simeon, Jean De Dieu Muragijimana, Sakina Rashid, David Msuya, Joseph Elisante, Meghna Solanki, Emmanuel Manjira, Jay Lodhia, Mubashir Jusabani, Murad Tarmohamed, Sengua Koipapi, Touabti Souhem, Nabti Sara, Brahimi Sihem, Bouguermouh Dania, Iaiche Achour Toufik, Baghdadi Nour el islam Mounira, Alouani Habiba, Liliana Aragão, Victor Gonçalves, Marcelo Mauricio Lino Urquizo, Maria Florencia Varela, Pedro Mercado, Bonavia Horacio, Andrea Damiani, Carlos Mac, Daniel Putruele, Karen Liljesthrom, Marianela Bernaus, Cesar Jauri, Alejandrina Cripovich, Ezequiel Bianchin, Maria Gabriela Puig, Lorna Andreussi, Susana Iracelay, Dolores Marcos, Carina Herrera, Nelly Palacios, Romina Avile, Belen Serezo, Debora Montoya, Rodrigo Cepeda, Justo Vaquila, Sofficci Veronica, Liliana Pardo, Pelussi Valeria, Lapalma Julio, Aranda Diego Martin, Palazzi Lucio, Comba Gabriel, Depetrini Marianella, José Alfredo Calderón Arancibia, Enrique Huespe, Gabriela Natalia Losa, Elsa Arancibia Gutiérrez, Humberto Scherl, Daniel Emilio Gonzalez, Valentina Baistrocchi, Yanina Silva, Marcelo Galdeano, Pablo Medard, Ines Sueiras, Enrique Romero Manteola, Victor Hugo Defago, Carlos Mieres, Carlos Alberto, Fabio Cornelli, Marcelo Molina, Pablo Ravetta, Celeste Carolina Patiño Gonzalez, Maria Belen Dallegre, Maria Tatiana Szklarz, Marcos Federico Leyba, Nahuel Ignacio Rivarola, Maria Delia Charras, Adriana Morales, Paloma Caseb, Luzia Toselli, Carolina Millán, Maria del Carmen Junes, Oscar Di Siervi, Jose Gilardi, Soledad Simon, Carla Sofia Contreras, Nair Rojas, Lucia Beatriz Arnoletto, Otilia Eva Blain, Mauro Nicolas Bravo, Nancy Sanchez, Luciana Martina Herrera Pesara, Maria Eugenia Moreno, Carlos Ariel Sferco, Umama Huq, Tamanna Ferdousi, Abdullah Al-Mamun, Sadia Sultana, Refoyez Mahmud, Khalid Mahmud, Fatema Sayeed, Alexander Svirsky, Denisse Sempertegui, Amalia Negrete, Araceli Teran, Mariana Sadagurschi, Nusret Popovic, Kenan Karavdic, Emir Milisic, Asmir Jonuzi, Amira Mesic, Sabina Terzic, Nejra Dendusic, Elna Biber, Anesa Sehic, Nada Zvizdic, Emina Letic, Adna Saracevic, Ajla Hamidovic, Nejra Selak, Dzan Horozic, Lamija Hukic, Amila Muhic, Nedim Vanis, Emir Sokolovic, Adnan Sabic, Karin Becker, Elis Novochadlo Klüppel, André Iván Bradley dos Santos Dias, Miguel Angelo Agulham, Cristiano Bischoff, Stella Sabbatini, Rachel Fernandes de Souza, Ana Beatriz Souza Machado, Juliana Werneck Raposo, Maria Lucia da Silva Augusto, Bianca M.R. Martins, Mariana de Souza Santos Ferreira, Darli Fernandes de Oliveira, Carla Silva dos Santos, Fernanda Ribeiro de Fernández y Alcázar, Érika Alves Dutra da Silva, Mariana Furtado, Horácio Tamada, Marília Silva Ferreira dos Santos, Thayná Lopes de Almeida, Susy Oliveira de Andrade, Antonio Cipriano Gurgel do Amaral, Lais Sartori Giovanoni, Kamila de Deus Passos Leles, Eduardo Corrêa Costa, Leticia Feldens, Luciano Ferraz Schopf, José Carlos Soares de Fraga, Felipe Colombo de Holanda, Paola Maria Brolin Santis Isolan, Julia Loyola Ferreira, Carla Luisa Bruxel, Danielle Lopes Teixeira Ferdinando, Fabricio Zottis Barcelos, Natalia Baseggio, Nicole Knorr Brenner, Rafael Trindade Deyl, Carolina Dure, Iuri Nunes Kist, Rafael Bueno Mazzuca, Sarah Bueno Motter, Yna Ramos, Cristine Suzana Trein, Bianca Rezende Rosa, Murilo de Assis Silva, Flavio Augusto Menin, Isabela Cristina Semensato Carloni, Juliana Antinarelli Norberto da Silva, Adriano Luis Gomes, Mariana Girão Tauffer, Paulo César Bassan Gonçalves, Geraldo Magela Nogueira Marques, Eliane Moriya, Carla Labonia, Ana Lucia Carrasco, Karine Furtado Meyer, Luiz Farion-Aguiar, Fernando Amado, Amanda Antunes, Elisângela Silva, Leila Telles, Giovana Almeida, Aluísio Augusto Belmino Gadelha, Flavia de Azevedo Belesa, Acimar Gonçalves da Cunha, Jr, Beatriz Souza Barros, Josiane Bernartt Zanellato, Patricia Guimarães, Karina Ilheu da Silva, Bianca Ribas, Cristina Reuter, Francis Tanise Casado, Mila Torii Correa Leite, Daniela Testoni, Ruth Guinsburg, Simone de Campos Vieira Abib, Edson Khodor Cury, Suely Dornellas do Nascimento, Arthur Almeida Aguiar, Rodrigo Melo Gallindo, Carolina Gonçalves Borges, Yang Liu, Cai Duote, Jinhu Wang, Zhigang Gao, Liang Liang, Wenjuan Luo, Xiaoxia Zhao, Rui Chen, Peng Wang, Yijiang Han, Ting Huang, Hu Donglai, Guo Xiaodong, Chen Junjie, Libin Zhu, Guowei Wu, Xiaozhou Bao, Haijing Li, Junying Lv, Zhongrong Li, Feng Yong, Zhou Chong Gao, Qiang Bai, Weibing Tang, Hua Xie, Jethishka Motee, Jianming Zhu, Gang Wen, Weiwei Ruan, Shungen Li, Lulu Chen, Shungen Huang, Zhibao Lv, Jinjing Lu, Liuming Huang, Mengnan Yu, Wang Dajia, Yu Zuo Bai, Luis Carlos Rincon, Juliana Mancera, Edgar Alzate Gallego, Laura Torres-Canchala, Nathalia Silva Beltrán, Ghordana Osorio Fory, Daniela Castaño Avila, Angelica Maria Forero Ladino, Juanita Gomez, Martha Jaramillo, Otto Morales, Beatriz Sanchez, Nestor Julien Tinoco Guzmán, Sergio Castañeda Espinosa, Osbaldo Prieto Vargas, Lina Maria Pardo, Eliana Toral, Freud Cáceres Aucatoma, Daniel Hinostroza, Santiago Valencia, Vicente Salinas, Enrique Landivar Cino, Gabriela Yulissa Ponce Fajardo, Miguel Astudillo, Virginia Garcia, Guillermo Muñoz, Leonardo Verduga, Ivan Verduga, Ericka Murillo, Elena Bucaram, Marisol Guayelema, Monica Marmol, Janina Sanchez, Carolina Vergara, Adriana Mena, Junior Velaña, Karla Salazar, Sandra Lara, Elena Chiriboga, Julian Silva, Dalia Gad, Doaa Samy, Menan Ahmed Elsadek, Hanan Mahmoud Mohammed, Mohamed Abouheba, Karim Osamy Ali, Hayssam Rashwan, Omar Moustafa Fawzy, Tarek mohamed Kamel, Rawan Nemer, Mohamed Abada Hassan, Eyad Hassan Falah, Dina Sobhy Abdelhady, Mostafa Zain, Eman Abouzeid Abouzeid Ibrahim, Omar Ossama Elsiraffy, Ahmed Aboelela, Eman mohamed Farag, Ahmed Mohamed Oshiba, Omar Sameh Emam, Alaa Mobarak Attia, Moustafa A. Laymouna, Islam Abdelmonem Ghorab, Mansour Mkayed Mohammed, Nourhan Akram Soliman, Khaled Abd elrahman Ghaly, Kareem Sadek, Mohamed Elsherbiny, Amr Saleh, Hesham Sheir, Tamer Wafa, Mohamed Abd Elmenam, Sherif Abdelmaksoud, Ahmed Reda, Islam Mansour, Mohamed Elzohiri, Basma Waseem, Mohamed Elewaily, Mohammed El-Ghazaly, Ahmad Elhattab, Amr Shalaby, Adham Elsaied, Ahmad Adawy, Mirna Sadek, Mahmoud Abdelfattah Ahmed, Mohamed Omar Herdan, Gena Mohamed Hamed Elassall, Azhar Arabi Mohammed, Mohammed Hamada Takrouney, Tarek Mohamed Essa, Ahmed Mokhtar Mahmoud, Alshaimaa M. Saad, Mariam Albatoul Nageh Fouly, Mahmoud abdelshakour Ibrahim, Mohammad Nageh, Mahmoud M. Saad, Helmy Badr, Mohamed Fayez Fouda, Ahmed Hassan Nofal, Hisham Almohamady, Mohamed Ahmed Arafa, Mohamed Amad, Mohamed Awad Mansour, Jennifer O'Connor, Zachary O'Connor, Nzanzu Anatole, Elysé Nkunzimana, Solomon Machemedze, Lemfuka Dieudonné, William Appeadu-Mensah, Theophilus Teddy Kojo Anyomih, Priscilla Alhassan, Francis A. Abantanga, Vishal Michael, Roshine Mary Koshy, Ankit Raj, Vijay Kumar, Sundeep PT, P Santosh Prabhu, Armin Vosoughi, Ali Farooq Al-Mayoof, Muhamed Jassim Fadhle, Ali Egab Joda, Hayder Nadhim Obaid Algabri, Sultan S. Abdelhamid, Hashem M. Al-Momani, Marzouq Amarin, Louay Y. Zaghlol, Nijmeh Nasser Alsaadi, Yasmeen Z. Qwaider, Hibah Qutishat, Ahmad Hasan Aliwisat, Esraa Arabiat, Isam Bsisu, Raghad M. Murshidi, Mohammad S. Jabaiti, Ziad A. Bataineh, Husam Aldean Abuhayyeh, Thekraiat M. Al Quran, Faris J. Abu Za'nouneh, Mohanad Mutasem Alebbini, Hamzah Abullah Qudah, Omar Ghazi Hussein, Amir M.I. Murad, Justin Z. Amarin, Haya H. Suradi, Sayel H. Alzraikat, Rand Y. Omari, Bashar M. Matour, Layana Al-Halbouni, Rajai O. Zurikat, Ahmad H. Yanis, Sara Al Hussein, Ali Shoubaki, Waleed H. Ghanem, Kuria David, Soita Wycliffe Chitiavi, Moraa Mose, Robert Mugo, James Ndungu, Timothy Mwai, Swaleh Shahbal, Janan Malik, Nirav Chauhan, Francisa Syovata, Kevin Ochieng, Polycarp Omendo Liyenzero, Syeda Ra'ana Hussain, Stanley Mugambi, Roseline Ochieng, Ebtesam Othman Abdulsalam Elkhazmi, Ala Khaled, Aya Albozidi, Manal Ben Enbaya, Mala Elgammudi, Enas Soula, Wegden ibrahim almabrouk Khalel, Yasmine Ali Elhajjaji, Nouriyah Ali Alwaggaa, Sumayyah Ghayth, Dafer abdulhakim .S. Zreeg, Sara Abobaker Tantush, Fatma Bibas, Tesneem Layas, Randa Alamen M Sharif, Wesal Omar F. Saied Aljadidi, Ahmed Tarek, Hazem Ahmed, Kamila Almabrouk Mohammed Essamilghi, Mabroka Alfoghi, Ma'aly A. Abuhlega, Saddam Arrmali, Fatima Mousa Abduljawad, Hasan Mustafa Alosta, Abdulsalam Abuajaila, Fakereldeen Abdelmutalib, Fatma Bashir, Inas Almengar, Mohammad hasan Annajjar, Abdelaziz Deyab, Fathi Elzowawi, Yousef Krayem, Weam Drah, Asma Meftah, Abobaker Mohammed, Lina Ali Arrmalli, Hajir Aljaboo, Abdallah Elayeb, Mohamed Altomi, Ahmed Altaweel, Mohamed Tumi, Hana Milad Bazozi, Aisha Shaklawoon, Mohammed Meftah Alglaib, Abdullahn Abdousalam Elkaloush, Sara Trainba, Hisham Swessi, Ali Alnaeri, Aya Essam Shnishah, Hamassat Mustufa, Sondas Ali Gargum, Sara Ali Tarniba, Hawa Ahmed Shalluf, Hajer Ali Shokri, Taher L. Sarkaz, Osama Tababa, Ahmed Elhadi, Vesna Cvetanovska Naunova, Laze Jovcheski, Marjan Kamilovski, Aleksandra Gavrilovska-Brzanov, Zarina Abdul Latiff, Siti Farhan Moh Pauzi, Marjmin Osman, Felicia Lim, Ainal Huda Abu Bakar, Azrina SK Zaman, Shareena Ishak, Rufinah Teo, Dr. Tammy Teoh Han Qi, Mohd Yusran Bin Othman, Dato' Dr Zakaria bin Zahari, Zulfitri bin Md Hassan, Cheah Hui Shan, Abhirrami Lechmiannandan, Hafatin Fairos bt Tamaddun, Mohd Fitri Shukri bin Mohamed Adanan, Mohd Yusof bin Abdullah, Wang Junyi, Mohd. Tarmizi Mohd Nor, Wan Ruzaimie Noor, Mohd Razin bin Hassan, Noor Fa'izatul Rahil Ambok Dalek, Hidayah Hayati binti Hashim, Ahmad Zulhisyam bin Zarwawi, V Muthualhagi M Vellusamy, Quah Soong Yuen, Hemasutha a/p Kannessan, Najua binti Ramli, Ahmad Shafiee bin Bujarimin, Jessmine Anntinea, Anthony Dass, Hazlina Mohd. Khalid, Nur Atiqah binti Mohd Hanifah, Keily Wong Yue Jyun, Rahilah binti Abd Razak, Nur Atifah binti Mohd Naim, Siti Nur Aien binti Hamid Hamzah, Cristian R. Zalles Vidal, Eduardo Bracho Blanchet, Roberto Dávila Perez, Emilio Fernandez Portilla, Raúl Villegas Silva, Daniel Ibarra, Antonio Calderon Moore, Cesar Carrasco-Ortega, Monica Noguez Castillo, Dorihela Herappe Mellado, Guillermo Yanowsky Reyes, Luis Fernando Gonzalez Cortez, Rafael Santana Ortiz, Jamie Orozco Perez, Jorge Román Corona C.Rivera, Juan Jose Cardenas Ruiz Velasco, Moises Quiles Corona, Christian Peña Padilla, Lucina Bobadilla Morales, Alfredo Corona Rivera, Izabel Maryalexandra Rios Flores, Cristian Irela Aranda Sánchez, Gabriela Ambriz-González, Nestor Martínez Hernández Magro, Francisco Javier León Frutos, José de Jesús Cárdenas Barón, Alejandro González Ojeda, Jessica Yarza Fernández, Juan Domingo Porras, Pastor Aguirre-Lopez, Vicente Sánchez Paredes, Arturo Montalvo Marin, Jose Manuel Diaz Gomez, Lorenzo Juvencio Caamal, David Bulnes Mendizabal, Pablo Sanchez Valladares, Humberto Garcia Martinez, Opeoluwa Adesanya, Moses Olanrewaju, Rilwan Adegboyega, Nurudeen Abdulraheem, Anuoluwapo Aremo, Florence Dedeke, Anyanwu Lofty-John Chukwuemeka, Mohammad Aminu Mohammad, Abdullahi Lawalbarau, Nwokoro Collins, Ogundele Ibukunolu, Amo Shonubi, Oluwaseun Ladipo-Ajayi, Olumide Abiodun Elebute, Justina Seyi-Olajide, Felix Alakaloko, George Ihediwa, Kayode Olayade, Christopher Bode, Olakayode Ogundoyin, Dare I. Olulana, Ifeanyichukwu Kelvin Egbuchulem, Felix O. Kumolalo, Ikechukwu Ulasi, Uchechukwu Obiora Ezomike, Sebastian Okwuchukwu Ekenze, Elochukwu Perpetua Nwankwo, Emmanuel Ifeanyi Nwangwu, Isaac Chukwu, Christopher Chim Amah, Nene Elsie Obianyo, Omolara Williams, Roland Iheanyichukwu Osuoji, Omolara Moronkeji Faboya, Olalekan Temitope Ajai, Moruf Adekunle Abdulsalam, Titiloye Hannah Agboola, Bolarinwa Bolanle Temilade, Maryrose Osazuwa, Morayo Monsurat Salawu, Eze Chukwuemeka Ejinkeonye, Mariya Mukhtar Yola, Amsa B. Mairami, Adekunle T. Otuneye, Matthias Igoche, Adebayo Gbenga Tanimola, Emmanuel Akinlabi Ajao, Efeturi Agelebe, Samson Olori, Philip Mari Mshelbwala, Olabisi Osagie, Adewale Oyinloye, Auwal M Abubakar, Lateef Oyebanji, Ibrahim Shehu, Cyril Cletus, Ahmed Bamanga, Faruk Suleiman, Sani Adamu, David C.Nwosu, Yahya S.Alkali, Iliya Jalo, Aliu Rasaki, Yusuf T.Sambo, Kalakwa A.Mohammed, Abubakar M.Ballah, Victor Modekwe, Okechukwu Hyginus Ekwunife, Ugochukwu S Ezidiegwu, Andrew N Osuigwe, Jideofor O Ugwu, Chuka A Ugwunne, Nadeem Akhter, Mudassir Fayaz Gondal, Rafee Raza, Ali Raza Chaudary, Hassan Ali, Muhammad Umar Nisar, Muhammad Umer Jamal, Ghuri Shankar Pandit, Uzma Mumtaz, Muhammad Bin Amjad, Nabila Talat, Wajeeh ur Rehman, Muhammad Saleem, Muhammad Bilal Mirza, Imran Hashim, Naveed Haider, Soban Hameed, Ayesha Saleem, Sohail Dogar, Muhammad Sharif, Muhammad Kashif Bashir, Fatima Naumeri, Zarqa Rani, Muath A.M. Baniowda, Basheer Ba'baa', Majd Yousef Mohammed Hassan, Ammar Darwish, Abrar Shaheen Sehwiel, Mohammed Shehada, Abrar ghassan Balousha, Yara Ajrami, Ainaa Ata Mohammad Alzamari, Bashar Yaghi, Hasan Subhi Hasan Abu Al-saleem, Mervat Sufian Abu Farha, Mohammad Omar Mohammad Abdelhafez, Firas Anaya, Asef belal Qadomi, Abd Al-Naser Bany Odi, Muath Abdelrahem Fuad Assi, Fadwa Sharabati, Ahmad Abueideh, Doha mustafa saleh Beshtawi, Hasan Arafat, Lara Zahi Adel Khatatba, Safa' Jamal Abatli, Hiba Al-Tammam, Dania Jaber, Yara Imad Omar Kayed, Ali Abdelhay Abumunshar, Rami Anwar Misk, Asmahan Mohammad Suliman Alzeer, Mutassem Sharabati, Ihsan Ghazzawi, Osama Majed Darras, Mahmoud M.Qabaja, Ma'alem sameer Hajajreh, Yasmeen Ahmad Samarah, Dua Hasan Yaghi, Moradallah Asad Fahmi Qunaibi, Abdelrazzaq Abu Mayaleh, Sharehan Joubeh, Annan Ebeido, Samer Adawi, Ihda Adawi, Mohammad Omar Ibrahim Alqor, Ahmad Samih Arar, Hadeel Awad, Fawzi Abu-Nejmah, Osaid Shaher Shabana, Firas Alqarajeh, Tareq Z. Alzughayyar, Jomana Madieh, Mahmoud Fuad Sbaih, Raghad mohammad abdu Alkareem, Raghad abdullateef Lahlooh, Yasmeen Adly Halabi, Wisam Baker, Tasneem Fathi Hasan Almusleh, Abdulraheem Adnan Abdulraheem Tahyneh, Yazid yousef mahmoud Atatri, Najlaa Abu Jamie, Nasrallah Ashraf Al Massry, Walaa Lubbad, Ayoub A.Nemer, Mohammed Alser, Aya Azmi Shehda Salha, Khaled Alnahhal, Aya Mahmoud Elmzyyen, Amir Talat Sheda Ghabayen, Abdulwhhab Ayman Abu Alamrain, Samar H. Al-Shwaikh, Omar Adly Elshaer, Nureddin Shaheen, Jehad Fares, Hisham Dalloul, Anas Qawwash, Mustafa abu Jayyab, Dina Ayman Ashour, Ahmad Ashraf Shaheen, Samy Rafat Ramadan Naim, Eman Abu Shiha, Nagham Mohammed Al Dammagh, Walaa Almadhoun, Ashraf Ayman Al-Salhi, Abdalkarim Yhya Hammato, Jamal Mohammed Salim, Doaa Khalil Hasanain, Soha Marwan Salem Alwadia, Ismail Nassar, Hala M. Al-Attar, Haya Abdulnasser Ali Alshaikhkhalil, Yasmin Mohammed Khalil Abu Jamie, Yara shareef Ashour, Sharif S. Alijla, Mohamed Anwer El Tallaa, Adham Ashraf Abuattaya, Bisan D.M. Wishah, MOHAMMED A.M. ALDIRAWI, Ahmed S Darwish, Sulaiman T. Alzerei, Nidal Wishah, Sharif Alijla, Isidora Garcia, Marlene Diaz Echegaray, Veronica Raquel Cañapataña Sahuanay, Fernando Trigoso Mori, Jackelyne Alvarado Zelada, Juan Jose Salinas Barreto, Porfirio Rivera Altamirano, Cesar Torres Miranda, Rocio Anicama Elias, Julio Rivera Alvarez, Juan Pedro Vasquez Matos, Fernando Ayque Rosas, Jesmarina Ledesma Peraza, Andrea Gutarra Palomino, Stephany Vega Centen, Victor Casquero, María Rosa Ortiz Argomedo, Francisco Lapouble, Genaro Llap Unchón, Florangel Patricia Delgado Malaga, Luis Ortega Sotelo, Segundo Gamboa Kcomt, Araceli Villalba Villalba, Nancy Rossana Mendoza Leon, Loreley Raquel Cardenas Alva, Maria Susana Loo Neyra, Cathy Lee Alanguia Chipana, Cintya Maria de Jesus Torres Picón, Natalia Huaytalla Quiroz, Danny Dominguez, Carlos Segura Calle, Jenny Arauco, Luis Ormeño Calderón, Ximena Ghilardi Silva, Miriam Daniela Fernandez Wilson, Joan Elizabeth Gutierrez Maldonado, Cesar Diaz Leon, Waldo Berrocal Anaya, Patricia Chavez Galvez, Prince Pamela Aguilar Gargurevich, Flor de Maria Diaz Castañeda, Carmen Guisse, Erika Ramos Paredes, Jose Luis Apaza Leon, Faye Aguilar Aguilar, Raul Ramirez De La Cruz, Lenny Flores Carbajal, Carlos Mendoza Chiroque, Gladys Johana Sulca Cruzado, Natalia Tovar Gutierrez, Jennifer Sotelo Sanchez, Carolina Paz Soldan, Karina Hernández Córdova, Edgar Fernando Delgado Quinteros, Luz Mery Brito Quevedo, Juan Jose Mendoza Oviedo, Angel Samanez Obeso, Patricia Paredes Espinoza, Johann de Guzman, Raisa Yu, Vlad Cosoreanu, Sebastian Ionescu, Aurel Mironescu, Lucian Vida, Adrian Papa, Roxana Verdeata, Bogdan Gavrila, Liviu Muntean, Marija Lukac, Miona Stojanovic, Djordje Toplicic, Milan Slavkovic, Andjelka Slavkovi, Dragoljub Zivanovic, Ana Kostic, Maja Raicevic, Delphine Nkuliza, Daniel Sidler, Corné de Vos, Elmarie vd Merwe, David Tasker, Omar Khamag, Cecilia Rengura, Thozama Siyotula, Uzair Jooma, Dirk von Delft, Marion Arnold, Hansraj Mangray, Shamaman Harilal, Sanele Madziba, Naveen Wijekoon, Tharanga Gamage, Benedict Paul Bright, Alaa Abdulrahman, Ola Ahmed Abdulmjeed Mohammed, Mohammed Salah, Ahmad Elian Abu Ajwa, Mohammed Morjan, Mohammad Mohannad Batal, Vivian Faks, Mohamad Bassel Mouti, Ahmadfateh Assi, Ahmad Al-Mouakeh, Ahmad Sankari Tarabishi, Ziad Aljarad, Aos Alhamid, Jiraporn Khorana, Wannisa Poocharoen, Sirima Liukitithara, Anan Sriniworn, Wasun Nuntasunti, Monawat Ngerncham, Ratiyaporn Phannua, Kanokrat Thaiwatcharamas, Patchareeporn Tanming, Lassaad Sahnoun, Nahla Kchiche, Roua Abdelmoumen, Egemen Eroğlu, Mehmet Ali Ozen, Hatice Sonay Yalçın Cömert, Mustafa İmamoğlu, Haluk Sarıhan, Şebnem Kader, Mehmet Mutlu, Yakup Aslan, Ahmet Beşir, Şükran Geze, Bahanur Çekiç, Ali Yalcinkaya, Kaan Sönmez, Ramazan Karabulut, Zafer Türkyılmaz, Kıvanç Şeref, Merve Altın, Merve Aykut, M.Eren Akan, Melisa Erdem, Ebru Ergenekon, Canan Türkyılmaz, Elif Keleş, Ali Canözer, Aslı Öztürk Yeniay, Elif Eren, İlknur Banlı Cesur, Zerrin Özçelik, Gökmen Kurt, Mustafa Kurthan Mert, Hatice Kaya, Müge Çelik, Suleyman Cuneyt Karakus, Nazile Erturk, Alev Suzen, Nilay Hakan, Fatih Akova, Mehmet Pasaoglu, Shukurali Eshkabilov, Rustam Z. Yuldashev, Dekhkonboev Avazjon Abdunomonovich, Aliev Makhmudjan Muslimovich, Azad Patel, Chisengo Kapihya, Nicholas Ensar, Ramesh M Nataraja, Mithila Sivasubramaniam, Matthew Jones, Warwick Teague, Sharman Tan Tanny, Gordon Thomas, Kiera Roberts, Soundappan Sannappa Venkatraman, Holger Till, Manon Pigeolet, Martine Dassonville, Anas Shikha, Win Sabai Phyu Win, Zahidah Adlynee Haji Ahmad, Léamarie Meloche-Dumas, Louise Caouette-Laberge, Dickens St-Vil, Ann Aspirot, Nelson Piché, Shahrzad Joharifard, Nadia Safa, Jean-Martin Laberge, Sherif Emil, Pramod Puligandla, Kenneth Shaw, Hussein Wissanji, Eileen Duggan, Elena Guadagno, Maria Consuelo Puentes, Paola Osses Leal, Carolina Mendez Benavente, Michal Rygl, Barbora Trojanová, Klára Berková, Tereza Racková, Ladislav Planka, Jan Škvařil, Radek Štichhauer, Shahad Sabti, Alex Macdonald, Nordeen Bouhadiba, Dorothy Kufeji, Caroline Pardy, Simon Mccluney, Alireza Keshtgar, Rebecca Roberts, Hannah Rhodes, Kate Burns, Robin Garrett-Cox, Kat Ford, Hannah Cornwall, Krithi Ravi, Felicity Arthur, Paul Losty, Tony Lander, Ingo Jester, Suren Arul, Oliver Gee, Giampiero Soccorso, Michael Singh, Max Pachl, Benjamin Martin, Afnan Alzubair, Arun Kelay, Jonathan Sutcliffe, Thomas Middleton, Amy Hughes Thomas, Merina Kurian, Fraser Cameron, Jayaram Sivaraj, Mark C Thomas, Dean Rex, Ceri Jones, Kate Bradshaw, Arnaud Bonnard, Xavier Delforge, Camille Duchesne, Caroline Le Gall, Coralie Defert, Samia Laraqui Hossini, Florent Guerin, Géraldine Hery, Virginie Fouquet-Languillat, Jules Kohaut, Aline Broch, Thomas Blanc, Luke Harper, Thomas Delefortrie, Quentin Ballouhey, Laurent Fourcade, Céline Grosos, Benoit Parmentier, Guillaume Levard, Maria Giovanna Grella, Mariette Renaux Petel, Lucie Grynberg, Olivier Abbo, Sofia Mouttalib, Mélodie Juricic, Aurelien Scalabre, Elodie Haraux, Anke Rissmann, Hardy Krause, Peter Goebel, Ludwig Patzer, Udo Rolle, Andrea Schmedding, Alexandra Antunez-Mora, Bernd Tillig, Sylvester von Bismarck, Patricia Reis Barbosa, Christian Knorr, Domitille Stark, Marco Brunero, Luigi Avolio, Francesco Manni, Matilde Molinelli, Marinella Guazzotti, Alessandro Raffaele, Piero Giovanni Romano, Silvia Cavaiuolo, Gian Battista Parigi, Laszlo Juhasz, Anna Rieth, Arunas Strumila, Rūta Dagilytė, Arunas Liubsys, Pranas Gurskas, Dalius Malcius, Agne Mikneviciute, Asta Vinskaite, Vidmantas Barauskas, Liam Vierboom, Timothy Hall, Spencer Beasley, Lucy Goddard, Mark Stringer, Naveen Weeratunga, Stephen Adams, Jitoko Cama, Marilyn Wong, Sridharan Jayaratnam, Askar Kukkady, Udaya Samarakkody, Sylwester Gerus, Dariusz Patkowski, Agnieszka Wolny, Tomasz Koszutski, Szymon Tobor, Marta Osowicka, Piotr Czauderna, Dariusz Wyrzykowski, Hanna Garnier, Stefan Anzelewicz, Osowicka Marta, Agata Knurowska, Alicja Weiszewsk, Andrzej Grabowski, Wojciech Korlacki, Michal Pasierbek, Przemyslaw Wolak, Aneta Piotrowska, Anna Roszkiewicz, Piotr Kalicińsk, Agata Trypens, Grzegorz Kowalewsk, David Sigalet, Amer Alsaied, Mansour Ali, Ameen Alsaggaf, Alaa Ghallab, Yazeed Owiwi, Ali Zeinelabdeen, Mohamed Fayez, Ahmed Atta, Mazen Zidan, Asaad saleh Radwan, Hanin Shalaby, Reem Abdelbaqi, Khalid Alattas, Yar Kano, Omar Sindi, Abdullah Alshehri, Tariq Altokhais, Fahad Alturki, Mohammad Almosaibli, Dasha Krisanova, Wisam Abbas, Hee-Beom Yang, Hyun-Young Kim, Joong Kee Youn, Jae Hee Chung, Seok Hyeon Cho, In ji Hwang, Ju yeon Lee, Eung song Song, Jenny Arboleda, Mercedes Ruiz de Temiño Bravo, Alexander Siles Hinojosa, Miriam García, Isabel Casal Beloy, Detlef Oliu San Miguel, Maria Elena Molina Vazquez, Verónica Alonso, Alberto Sanchez, Oscar Gomez, Isabel Carrillo, Tomas Wester, Carmen Mesas Burgos, Martin Salö, Erik Omling, Niclas Rudolfson, Christina Granéli, Helena Arnadóttir, Emma Grottling, Kate Abrahamsson, Vladimir Gatzinsky, Michaela Dellenmark Blom, Daniel Borbonet, Paul Puglia, Vinicio Jimenez Morejon, Gaston Acuna, Mario Moraes, Jonathan Chan, Pavan Brahmamdam, Alan Tom, Karen Sherer, Brandy Gonzales, Aaron Cunningham, Sanjay Krishnaswami, Reto Baertschiger, Mary Leech, Regan Williams, Lauren Camp, Ankush Gosain, Maria Mora, Bailey D. Lyttle, Jeremy Chang, Lydia McColl Makepeace, Kathryn L Fowler, Sara Mansfield, Erica Hodgman, Chukwubinyelum Amaechi, Alana Beres, Mark N. Pernik, Luke J. Dosselman, Murad Almasri, Sunil Jain, Varun Modi, Marianelly Fernandez Ferrer, John Coon, Joann Gonzalez, Medhavi Honhar, Nensi Ruzgar, Griffin Coghill, Sarah Ullrich, Maija Cheung, Katrine Løfberg, Jodie Greenberg, Kate Davenport, Samir Gadepalli, Sarah Fox, Stephanie Johnson, Mercedes Pilkington, April Hamilton, Nicole Lin, Juan Sola, Yang Yao, Jenna Kylene Davis, Monica Langer, Jonathan Vacek, Fizan Abdullah, Julie Khlevner, William Middlesworth, Marc Levitt, Hira Ahmad, Sabina M Siddiqui, Alex Bowder, Terry Derks, Afua Amoabin Amoabin, Brooke Pinar, Frank Owusu-Sekyere, Benmanseur Saousen, Rasika Naidoo, Azra Karamustafic, Danielle Paula de Oliveira, Jerhy Andrade, Antonín Šafus, Jason Langley, Alexandra Wilke, Corazone Deya, Habib Mansour Murtadi, Mindaugas Berzanskis, Nwachukwu Calistus, Olalekan S. Ajiboye, Michael Felix, Osagie O Olabisi, Seçil Erçin, Teymursha Muradi, Stephen S. Burks, Sergio Lerma, Jillian Jacobson, Calin Calancea, Rafael Valerio-Vazquez, Guigui Sikwete, Owusu Sekyere, Akhona Mbonisweni, Shahnoor Syed, Cho Seok Hyeon, Fatemeh Pajouhandeh, Sheba Mary Pognaa Kunfah, Global PaedSurg Research Collaboration, and Tıp Fakültesi

Subjects
Male, Pediatrics, medicine.medical_specialty, Adolescent, Gastrointestinal Diseases, Psychological intervention, Disease, Global Health, Specialties, Surgical, Congenital Abnormalities, Cohort Studies, medicine, Humans, Prospective Studies, Prospective cohort study, Child, Developing Countries, business.industry, Gastroschisis, Developed Countries, Intestinal atresia, Infant, Newborn, Gestational age, Congenital diaphragmatic hernia, Infant, Articles, General Medicine, medicine.disease, Gastrointestinal Tract, Atresia, Child, Preschool, Female, business
Abstract

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p

Published
2020

11. Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania

Author

Kokila Lakhoo, Godfrey Sama Philipo, Zaitun M Bokhary, and Shobhana Nagraj

Subjects
International Cooperation, Context (language use), Pediatrics, Tanzania, lcsh:Infectious and parasitic diseases, paediatrics, surgery, 03 medical and health sciences, 0302 clinical medicine, Nursing, Humans, lcsh:RC109-216, 030212 general & internal medicine, Child, Health policy, Budget constraint, lcsh:R5-920, Practice, biology, Surgical care, Public Health, Environmental and Occupational Health, Citizen journalism, health policy, biology.organism_classification, 030220 oncology & carcinogenesis, General partnership, Surgical Procedures, Operative, Workforce, child health, Business, lcsh:Medicine (General)
Abstract

Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children’s surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children’s surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children’s surgery in LMICs.

Published
2020

12. Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa

Author

Geoffrey Buckle, Godfrey Sama Philipo, Sadiq Siu, Jerry Ndumbalo, Elia John Mmbaga, Nanzoke Mvungi, Julius Mwaiselage, Msiba Selekwa, Rebecca DeBoer, Tracy Kuo Lin, Mamsau Ngoma, Sarah K. Nyagabona, Katherine Van Loon, Stephen Meena, Rohan Luhar, Beatrice Mushi, Lindsay Breithaupt, and Stephanie Kennell-Heiling

Subjects
lcsh:R5-920, Process management, Operationalization, Implementation strategy, Computer science, Behavior change, Health services research, Behavior change methods, Guideline, Cancer guidelines, Health administration, Study Protocol, 03 medical and health sciences, Intervention mapping, 0302 clinical medicine, 030220 oncology & carcinogenesis, Needs assessment, 030212 general & internal medicine, lcsh:Medicine (General), Guideline implementation
Abstract

Background Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. Methods In preparation for the launch of Tanzania’s first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. Discussion We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of “proven” guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.

Published
2020

13. Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania

Author

Elia John Mmbaga, Katherine Van Loon, Msiba Selekwa Nyeriga, Ronald Balassanian, Amie Y. Lee, Li Zhang, Beatrice Mushi, Sujay Sheth, Godfrey Sama Philipo, Dianna Ng, Edda Vuhahula, Kristie L. White, and Emily G Waterhouse

Subjects
Image-Guided Biopsy, Male, Cancer Research, medicine.medical_specialty, Biopsy, Biopsy, Fine-Needle, education, Specialty, Practicum, Tanzania, lcsh:RC254-282, 03 medical and health sciences, 0302 clinical medicine, Aspiration biopsy, Medicine and Health Sciences, medicine, Original Report, Humans, Medical physics, 030212 general & internal medicine, Medical diagnosis, Simulation Training, Ultrasonography, medicine.diagnostic_test, biology, business.industry, biology.organism_classification, lcsh:Neoplasms. Tumors. Oncology. Including cancer and carcinogens, Ultrasound guided, Fine-needle aspiration, Oncology, 030220 oncology & carcinogenesis, Fine-Needle, Biomedical Imaging, Female, business
Abstract

Background Fine-needle aspiration biopsy (FNAB) is a minimally invasive, cost-effective diagnostic tool that can be used in low-resource settings. However, adequacy and accuracy of FNAB is highly dependent on the skills of the operator and requires specialized training. Poor technique can preclude definitive diagnoses because of insufficient quality or quantity of FNAB samples. We evaluated the efficacy of an intensive training experience in Tanzania on improving ultrasound-guided FNAB techniques. Methods A 2-day workshop offered didactic lectures, demonstrations, and hands-on practicum on fundamentals of ultrasound imaging and FNAB technique. A prospective interventional study design was used with pre- and postintervention surveys and assessments to measure the effect of the workshop on specific skills related to slide smearing and ultrasound-guidance among participants. Results Twenty-six pathologists and radiologists, including trainees in each specialty, participated in the workshop. Pre- and postworkshop assessments demonstrated that most participants improved significantly in nearly all technical skills for slide smearing and ultrasound-guided FNAB. After the workshop, most participants demonstrated substantial improvements in ability to prepare the ultrasound equipment, measure the lesion in three dimensions by ultrasound, target lesions in one pass using both parallel and perpendicular approaches, and prepare high-quality aspirate smears. Conclusion An in-country 2-day workshop in Tanzania was efficacious in transferring basic skills in FNAB smear preparation and ultrasound-guided FNAB, resulting in skills enhancement among participating pathologists and radiologists. Although mastery of skills was not the goal of this short workshop, participants demonstrated proficiency in most technical elements after workshop completion, and the workshop generated interest among select participants to pursue additional intensive training in cytopathology.

Published
2018

14. Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania.

Author

Ng DL, Vuhahula E, Zhang L, Waterhouse EG, White KL, Mushi BP, Nyeriga MS, Philipo GS, Mmbaga EJ, Sheth S, Van Loon K, Lee AY, and Balassanian R

Subjects
Female, Humans, Male, Tanzania, Biopsy, Fine-Needle methods, Image-Guided Biopsy methods, Simulation Training methods, Ultrasonography methods
Abstract

Background: Fine-needle aspiration biopsy (FNAB) is a minimally invasive, cost-effective diagnostic tool that can be used in low-resource settings. However, adequacy and accuracy of FNAB is highly dependent on the skills of the operator and requires specialized training. Poor technique can preclude definitive diagnoses because of insufficient quality or quantity of FNAB samples. We evaluated the efficacy of an intensive training experience in Tanzania on improving ultrasound-guided FNAB techniques., Methods: A 2-day workshop offered didactic lectures, demonstrations, and hands-on practicum on fundamentals of ultrasound imaging and FNAB technique. A prospective interventional study design was used with pre- and postintervention surveys and assessments to measure the effect of the workshop on specific skills related to slide smearing and ultrasound-guidance among participants., Results: Twenty-six pathologists and radiologists, including trainees in each specialty, participated in the workshop. Pre- and postworkshop assessments demonstrated that most participants improved significantly in nearly all technical skills for slide smearing and ultrasound-guided FNAB. After the workshop, most participants demonstrated substantial improvements in ability to prepare the ultrasound equipment, measure the lesion in three dimensions by ultrasound, target lesions in one pass using both parallel and perpendicular approaches, and prepare high-quality aspirate smears., Conclusion: An in-country 2-day workshop in Tanzania was efficacious in transferring basic skills in FNAB smear preparation and ultrasound-guided FNAB, resulting in skills enhancement among participating pathologists and radiologists. Although mastery of skills was not the goal of this short workshop, participants demonstrated proficiency in most technical elements after workshop completion, and the workshop generated interest among select participants to pursue additional intensive training in cytopathology.

Published
2018
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